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FOOD IN 
HEALTH AND DISEASE 



DAVIS 



FOOD IN 
HEALTH AND DISEASE 



BY 

NATHAN S. DAVIS, JR., A. M., M. D., 

PROFESSOR OP THE PRINCIPLES AND PRACTICE OP MEDICINE IN NORTHWESTERN UNI- 
VERSITY MEDICAL SCHOOL; PHYSICIAN TO ST. LUKE'S HOSPITAL, MERCY HOSPITAL 
AND WESLEY HOSPITAL, CHICAGO*, MEMBER AMERICAN MEDICAL ASSOCIA- 
TION, AMERICAN CLIMATOLOGICAL SOCIETY, ETC. 



SECOND EDITION 



PHILADELPHIA 

BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
1912 






Copyright, 1912, by P. Blakiston's Son & Co. 



THE. MAPLE. PRESS. YORK- PA 



©CI.A328345 



PREFACE TO SECOND EDITION 



This book was written originally for "A System of Physiologic 
Therapeutics" so ably planned and edited by Dr. Solomon 
Solis Cohen. The title given to this series of treatises devoted 
to nonmedicinal therapeutics has been generally adopted 
as the best and most expressive for the methods discussed. 
At the time of its appearance the information contained in it 
could not be found in any other one place, and it has aided 
in calling forth much valuable study and many useful publica- 
tions. This volume was devoted to a subject which had 
been written upon frequently but by few American authors 
with as much fullness. 

In revising it much of it has been rewritten and additions 
have been made to almost every subject discussed in it. 
This was made necessary by additions to our knowledge of 
physiology and of the management of diseases by diet. More- 
over, the presentation of this volume to the public independent 
of its original setting in "A System of Physiologic Thera- 
peutics" has made some changes necessary. 

A description of the principles of dietetics has been attempted, 
as well as a full and practical consideration of the problems of 
diet and their solution in health and in the most important 
diseases. 

It is hoped that by explaining the principles and the limita- 
tions of dietetic treatment in each disease it will be easy for 
physicians and nurses to construct appropriate menus for 
individual patients. 

N. S. Davis. 
Chicago, 8 East Huron St. 



PREFACE TO FIRST EDITION 



It has been my aim to make as practical a book upon dietetics 
as possible. For that reason the diet best suited in individual 
diseases has been described fully under the heading of each 
ailment, although this has necessitated some repetition. The 
preservation of health is of as much importance as the treat- 
ment of the sick, and in order that the food may be adapted 
to both these purposes the principles underlying its use must 
be understood. It has therefore seemed best to review the 
chemical and physiologic data concerning the nutritive and 
other qualities of various kinds of food; to discuss briefly their 
relations to the digestive organs and to the organism as a 
whole; and to trace many of the changes that food must 
undergo before it can be appropriated to the needs of the 
human system and prepared for elimination. The first part 
of this volume treats of these subjects, with such brevity as 
has seemed compatible with thoroughness. For a similar 
reason, in the section devoted to the consideration of diet for 
invalids, attention has been given to the causation of disease, 
especially as diet, and digestive and nutritional processes are 
related to it. Symptoms are described whenever it seems best 
in order to make clear the indications for dietetic and general 
hygienic treatment. 

I wish to call special attention to the numerous studies of 
food and dietetics prosecuted under the auspices of the United 
States Department of Agriculture, and under the supervision of 
Professor Atwater. The value of these investigations is not 
fully appreciated by the medical profession, yet they constitute 
the most valuable original contributions to this subject that 
have emanated from America, and rank with the best studies 
made in other countries. I have, therefore, made numerous 
quotations from them. Use has been made also of standard 
works upon dietetics, and of monographs and case reports b}' 

vii 



Mil PREFACE TO FIRST EDITION. 

various writers, to whom I thus make acknowledgment. I 
have likewise availed myself of the valuable analytic studies to 
be found in the recently published treatise of Hutchison on 
"Food and the Principles of Dietetics," which came to hand 
while I was revising the manuscript of this volume. The 
recommendations made both as to diet for invalids and as to 
diet for persons in health under various conditions, are, 
however, largely based upon my own observation. 

N. S. Davis, Jr. 
Chicago. 



CONTENTS 



PAPT I— GENERAL PRINCIPLES OF DIET AND DIET IN HEALTH 

CHAPTER I 

Page 

Food in Health, 3 

General Pysiologic Considerations. Composition of Human 
Body and of Foods. Alteration of Foods in Process of 
Digestion, Absorption, and Utilization. Classification. 

CHAPTER II 

The Uses op Water, 7 

Uses of Water. Effect of too Little and of too Much 
Water. Amount of Water Used. Effect of Water in 
Health and Disease. Impurities in Water. Purification 
of Water. Kinds of Water. 

CHAPTER III 

The Elements of Food, 18 

Proteins — Digestion, Assimilation, Elimination; Effects in 
Health and Disease. Fats and Oils — Uses; Digestion and 
Assimilation; Effects in Health and Disease; Butter; 
Cream; Cod-liver Oil. 

CHAPTER IV 

The Elements of Food (Continued), 29 

Carbohydrates — Composition; Digestion; Abnormal Fer- 
mentation; Absorption. Action of Liver. Utility in 
Health and Disease. Interrelationship of Foods. Effect 
of Changes of Diet. Salts. 

CHAPTER V 

Quantity and Kinds of Food Needed in Health, ... 40 

Alimentary Equilibrium. Proteins and Calories. Dietary 
Standards. Army and Navy Dietaries. Prison Dietaries. 
Diet of Savages. Investigations of Actual Dietaries in the 
United States. 

ix 



X CONTENTS. 

CHAPTER VI 

Page 

Animal Foods, 68 

Milk and Milk Products. Composition. Variation. 
Adulteration. Contamination. Sterilization and Pas- 
teurization. Digestion. Absorption. Predigestion. 
Kephyr. Kumiss. Matzoon. Cream. Butter. Buttermilk. 
Cheese. 

CHAPTER VII 

Animal Foods (Continued), 88 

Eggs. Meats. Cooking. Meat Products. Digestibility. 
Food Value. Fish. 



CHAPTER VIII 

Vegetable Foods, 107 

Digestibility. Sugars. Cereals. Roots and Tubers. 
Peas and Beans. Green Vegetables. Fruits. Nuts. 
Fungi and Algae. Spices and Condiments. 

CHAPTER IX 

Beverages, 129 

Tea. Coffee. Cocoa. Alcoholic Beverages. 

CHAPTER X 

Diet in Health, 151 

Diet for Athletes in Training. Diet for Brain Workers. 
Starvation. Diet in Different Periods of Life. 

CHAPTER XI 

Infant Feeding, 171 

Mother's Milk. Irregularity in Feeding. Rules for Infant 
Feeding. 

CHAPTER XII 

Infant Feeding (Continued), 181 

Substitutes for Mother's Milk. Peptonization of Milk. 
Food for Premature Infants. Mixed Feeding. Weaning. 
Diet for Children. 



CONTENTS. 

CHAPTER XIII 

Food as a Cause of Disease, 

Ill Effects of Food. Parasites and 
Poisoning by Food. Idiosyncrasies. 



XI 



Page 
200 



Micro-organisms . 



PART II— DIET IN DISEASE 



CHAPTER I 

Feeding the Sick, 

General Considerations of Diet of the Sick. 
Foods. Fats and Oils. Rectal Feeding. 



207 



Concentrated 



CHAPTER II 

Diet in Infectious Diseases, 

Typhoid Fever. Typhus Fever. Dysentery. Yellow 
Fever. Cholera. Dengue. Relapsing Fever. 



214 



CHAPTER III 

Diet in Infectious Diseases (Continued), 

Smallpox. Scarlet Fever. Measles. Erysipelas. Septice- 
mia and Pyemia. Malaria. Tuberculosis. Influenza. 
Whooping-cough. Cerebrospinal Meningitis. Diphtheria. 
Rheumatism. 



230 



CHAPTER IV 

Diet in Diseases of the Stomach, 

Dysphagia and Odynophagia. Vomiting. Dyspepsia. 
Acute Gastritis. Chronic Gastritis. Dilated Stomach. 
Gastric Ulcer. Gastric Cancer. 



260 



CHAPTER V 

Diet in Diseases of the Intestines, Liver, and 

Peritoneum, 

Diarrhea. Diarrhea in Infants. Cholera Infantum. 
Enterocolitis. Chronic Enterocolitis. Appendicitis. In- 
testinal Obstruction. Constipation. Catarrhal Jaun- 
dice. Obstructive Jaundice. Cholelithiasis. Cirrhosis of 
the Liver. Peritonitis. 



2S8 



Xll CONTENTS. 

CHAPTER VI 

Page 

Diet in Diseases of the Respiratory Organs, 312 

Laryngitis. Laryngismus Stridulus. Bronchitis. Em- 
physema. Asthma. Croupous Pneumonia. Pleurisy 
and Empyema. 

CHAPTER VII 

Diet in Diseases of the Blood 321 

Simple Anemia. Chlorosis. Pernicious Anemia. Leuke- 
mia. Pseudoleukemia. 

CHAPTER VIII 

Diet in Diseases of the Circulatory Organs, ...... 334 

Acute Pericarditis and Endocarditis. Acute Dilatation. 
Weak Heart. Palpitation. Angina Pectoris. Aneurysm 
of the Aorta. Arteriosclerosis. 

CHAPTER IX 

Diet in Diseases of the Kidneys, > . . 345 

Nephrolithiasis. Albuminuria. Uremia. Passive Conges- 
tion of the Kidneys. Acute Nephritis. Chronic Diffuse 
Nephritis. Interstitial Nephritis. Pyelitis. 

CHAPTER X 

Diet in Diseases of the Nervous System, 364 

Neuralgias. Migraine. Neurasthenia and Hysteria. In- 
somnia. Epilepsy. Mental Diseases. 

CHAPTER XI 

Diet in Diseases of the Skin, 377 

Eczema. Acne Rosacea. Acne. Furunculosis. Urti- 
caria. 

CHAPTER XII 

Diet in Disorders of Nutrition, 382 

Emaciation. Obesity. Rachitis. Osteomalacia. Beri- 
Beri. Diabetes. Rheumatoid Arthritis. Gout and Gouti- 
ness. 

Index 427 



PART I 

GENERAL PRINCIPLES OF DIET AND 
DIET IN HEALTH 



FOOD IN HEALTH AND DISEASE 



PART I 

GENERAL PRINCIPLES OF DIET AND DIET 
IN HEALTH 



CHAPTER I 

FOOD IN HEALTH 

General Physiologic Considerations. Composition of Human 
Body and of Foods. Alteration of Foods in Process of Digestion, 
Absorption, and Utilization. Classification. 

Dietotherapy is the application of foods to the preservation of 
strength, flesh, and energy, or to their repair when diminished 
by disease. Necessarily the value of foods in health must be 
understood in order to appreciate their relative utility in disease. 

The human body contains the following chemical elements : 
Carbon, hydrogen, oxygen, nitrogen, sulphur, phosphorus, 
chlorin, iodin, potassium, sodium, calcium, magnesium, and 
iron. A few other elements have been found in the human 
body, but they are not uniformly present. The first four 
named occur in much larger proportions than the others. It 
is self-evident that food that is to make an infant's body 
grow to man's dimensions and capacity must contain these 
elements. It is, however, impossible to feed human beings 
upon chemical elements. To be useful they must be furnished 
in certain combinations. 

The following table shows the composition of foods. In the 
processes of digestion and assimilation many of these com- 
pounds are transformed into others which are peculiar to the 
human body. Therefore the chemical composition of the 
human body is not an adequate guide to the foods which are 
useful. 



FOOD IN HEALTH. 



Food- 
stuffs 



Inorganic 



Water. 



Salts 



Organic 



Carbohy- 
drates 



Fat 



Proteins 



Nad, KC1. 

Na 2 C0 3 , MgCOs. 

NajS04, K2SO4, MgSO<. 

Na 2 HP04, K2HPO4, MgHP04, CaHPO*. 

Na, K, Ca, etc., combined with fruit acids — 
tartaric, citric, malic, etc. 

Fe combined with animal products (hemoglo- 
bin) and with vegetable compounds (chloro- 
phyll). 



Monosaccharides 

Hexoses. 
Pentoses 



Disaccharides. 



Trisaccharides. 



Polysaccharides. 



f Dextrose. 

^ Levulose, etc. 



Maltose. 
Lactose. 
Sucrose, etc. 
Raffinose. 

Starches. 

Gums. 

Celluloses. 



Palmatin. 
Stearin. 
Olein. 
Butyrin, etc. 

Simple proteins. 



Congugate proteins. 



Products of protein 
hydrolysis. 



f Albumins. 

\ Globulins, etc. 

Nucleo-proteins, 
etc. 



Proteoses. 
Peptones, etc. 



Utilization of Food 

Although food has been adapted to the needs of the tissues by- 
digestion, it must undergo still further chemical modification 
when it is selected by cells for their repair, is stored in them, 
or by contact with them is decomposed to generate heat or 
muscular power. 

Food is not consumed in the stomach as coal in a furnace — 
to produce heat and energy. It must be prepared by digestion ; 
it must be absorbed; it must be modified by the liver, by the 
thyroid gland or its secretions, and by other glands ; it must be 
selected by such cells as need it ; it must be modified chemically 



UTILIZATION OF FOOD. 5 

and physically each time before it serves its purpose of con- 
tributing to growth and strength, to the production of heat 
and muscular and nervous energy, to the formation of secre- 
tions, and to reproduction. Finally, remnants of food that 
are not utilized may in part have to undergo additional changes 
to prepare them for elimination from the body by the skin, 
the lungs, the liver, the intestines, or the kidneys. 

As the utilization of food involves such numerous modifica- 
tions of its form and character before it is finally adapted to 
the needs of the various tissues of the body, it is evident that 
very many breaks may take place in the series of changes that 
it must undergo, destroying its value or even making it harmful. 
Food must be adapted not only to the needs of the digestive 
organs, but to the capabilities of other tissues to elaborate it 
still more, and finally to appropriate it. When the digestive 
organs are diseased, food must evidently be adapted to the 
digestive disturbances that have been produced. But even 
when primary digestion is well performed, some other metabolic 
failure may call for consideration in the adaptation of a diet. 
For example, in diabetes food must be adapted to the ability 
of the liver to retain sugar or of the tissues to utilize it. In 
this malady diet is not regulated by the ability to digest foods. 

In pathologic states of the human body various kinds of food, 
or for the time, all food, may be harmful. For example, when 
elimination by the kidneys is greatly lessened or suppressed, 
nitrogenous food, potassium, extractives, etc., may provoke 
uremic poisoning. When the stomach fails to secrete sufficient 
gastric juice and performs its normal churning movements 
infrequently and imperfectly, food will be digested in it 
slowly and disintegrated imperfectly; decomposition will 
almost surely take place and give rise to chemical compounds 
that are unnatural and noxious to the viscus. Even when all 
the bodily functions are being normally performed, too great 
a quantity of food of a certain kind may do harm. In certain 
conditions, as when the stomach is acutely inflamed or when 
vomiting is persistent, it may be necessary to abstain from 
food for a time in order to rest the stomach. 

These statements are made to emphasize a fact often lost 
sight of in the prescription of diet: that it is not sufficient to 



6 FOOD IN HEALTH. 

adapt food to the power of the stomach and the intestines to 
digest and absorb it ; the complex processes of utilization after 
digestion and of elimination of waste must likewise be kept in 
mind. 
Classification 

Foods may be variously classified. For instance, they may 
be divided into organic and inorganic; those belonging to the 
former, into animal and vegetable groups. Physiologists find 
the following chemical classification the most convenient : 

Water. 
Proteins. 
Fats. 

Carbohydrates . 
Mineral salts. 

It is necessary to trace the passage of each of these groups 
of foods through the system. The therapeutist, however, 
cannot administer simple chemicals such as these, but is 
obliged to give them in mixtures of various composition. For 
illustration, the mineral salts that the human body needs are 
partly obtained in spring-water and partly in meat, in vege- 
tables, and in cereals. Although proteins predominate in 
meat, fats and salts are also found in it. Milk contains water, 
proteins, fats, carbohydrates, and mineral salts. It is there- 
fore necessary to consider the complex composition of each 
article of diet. For convenience, however, we may classify the 
various kinds of foods by the ingredient that predominates in 
them, as water, protein, fat, or carbohydrate. The thera- 
peutist must study not only the chemical composition of 
foods, but also their palatability, digestibility, assimilability, 
and capability of elimination; and give attention likewise to 
the best methods of preparation and administration. All these 
qualities and conditions affect the dietetic value of individual 
articles. 



CHAPTER II 

THE USES OF WATER 

Uses of Water. Effect of too Little and of too Much Water. 
Amount of Water Used. Effect of Water in Health and Disease. 
Impurities in Water. Purification of Water. Kinds of Water. 

Water is of the greatest importance for the maintenance of 
life. It constitutes about 60 per cent, of the human body. 
S. Solis Cohen has rightly said that "the cells of the body are 
aquatic in their habit." They not only are composed largely 
of water, but are bathed by it more or less freely. Even the 
skin is coated at times with a perceptible, at other times with 
an imperceptible, film of it. 

It enters into the chemical composition of the tissues. It 
constitutes much the largest proportion of all the fluids of 
the body. By keeping serous and mucus surfaces moist it 
prevents friction and the distress which their drying would 
cause. In the blood and lymph it helps to carry food to all 
parts of the body and to eliminate waste matter. It helps to 
distribute body heat and to regulate it by the physical pro- 
cesses of absorption and evaporation. 

All living things soon die if deprived of water. Man can 
abstain from eating for weeks, but he cannot live and be 
deprived entirely of water for more than a very few days, 
and much distress is caused in a few hours. When abstinence 
from water is enforced, the first noticeable change is dimin- 
ished secretion of fluid by various glands; therefore the skin, 
the mouth, the stomach, and the intestinal canal become 
abnormally dry. The free action of the kidneys is interfered 
with. Thirst is felt keenly. Next the tissues lose their water 
and the body diminishes rapidly in size and may even become 
emaciated. The muscles lose their power to act. The mind 
is affected, possibly in part from the drying of nerve tissues; 
probably chiefly from the failure to eliminate toxins naturally 
formed by tissues. Delirium develops, and finally coma and 
death ensue. 



8 THE USES OF WATER IN DIETETICS. 

Deleterious results may also occur from the too free use of 
water. Physicians see cases of indigestion almost every summer 
that have gradually been provoked by too copious drinking. 
Such cases occur almost exclusively among those who are per- 
forming laborious work in very hot places. After a day or two of 
excessive water-drinking, appetite for solid food lessens and 
some gastric distress, usually a sense of fullness and distention, 
is noticed. Later flatulence, sour stomach, vomiting, and 
sometimes purging occur; this is due to the fact that gastric 
juice is so diluted that it can digest but little food, and that 
but slowly. Although appetite is lessened, more food is 
eaten than can be digested before putrefaction or abnormal 
fermentation takes place. The products of these latter 
changes excite vomiting, or purging and sometimes both. Most 
frequently these changes are assisted by indiscretion in eating. 

The quantity of water needed by a man varies greatly under 
diverse conditions. It may be said, however, that an average 
of from fifty to sixty ounces of water is required each day; 
twenty-five ounces more are obtained from the so-called solid 
food of which water constitutes an average of 50 per cent. If 
we say that from two to four pints or from four to eight glasses 
of water are required daily, the quantity may be more readily 
comprehended. The variations in the needs of individuals are 
due to: (1) Their varying size; (2) the character of the food they 
eat; (3) the quantity and kind of labor they perform; (4) the 
temperature of the air; (5) the dryness of the air. A small 
woman or a child needs less water than a large man. Some 
fruits and vegetables contain as much as from 90 to 95 per 
cent, of water; meats, from 60 to 80 per cent.; and some 
articles of food, 10 per cent, and less. The amount of water 
required as fluid will, therefore, necessarily, vary with the 
character of the food ingested. If the surrounding air is hot, 
evaporation from the skin and lungs will take place rapidly 
and must be compensated for by drinking. The rapidity of 
such elimination is increased greatly if the air is both dry and 
hot. Physical labor also provokes perspiration, deep and more 
vigorous breathing, and therefore elimination from the skin 
and lungs. Oertel has demonstrated that the elimination of 
fluid by these channels was much greater during mountain 



ELIMINATION. 9 

climbing than when the same distance was traveled upon a 
level. Therefore the character of work done influences the 
craving of the system for water. 

Water is eliminated by the skin, the lungs, the kidneys, and 
the feces. The variability of action of the skin and lungs has 
just been illustrated. The kidneys are particularly sensitive 
to the existence in the stomach and intestines of water in 
quantities greater than are actually required, and respond by 
eliminating rapidly a part of that which is in the blood, to 
permit the absorption of the former. The kidneys act most 
freely in cold weather, when the skin is least active. If stools 
of a liquid character are passed frequently, elimination of 
water by the kidneys is lessened. Because of the varying 
activity of these organs a statement can be made of only 
the average elimination by each of them. Approximately, 28 
per cent, of the water eliminated escapes from the body 
through the skin; 20 per cent, through the lungs; 50 per cent, 
through the kidneys; and 2 per cent, through the feces. 

Water is absorbed almost exclusively from the intestines. A 
comparatively small quantity may be absorbed from the 
stomach, and possibly a trifle from the mouth. It is taken up 
by the portal veins and the lymphatics. Not only does the 
quantity of water swallowed and eliminated vary, but also 
does the ability of the intestines to absorb it. In health this 
function of the alimentary canal changes little, if at all ; but in 
pathologic- conditions — as, for instance, in cholera, severe 
diarrhea, and dysentery — there is often evacuation from the 
mucous membrane of the intestines rather than absorption by it. 

Most persons drink too little water rather than too much. 
Especially is this true of those who lead a sedentary life, and 
of many others during the winter season. It is necessary, 
therefore, whenever elimination seems imperfect, to inquire 
as to the quantity of water and other fluids that is being 
consumed daily. From four to eight glasses are required by 
the average person. Under exceptional circumstances this 
allowance must be increased. 

The temperature of drinking-water should be governed by 
the needs of the stomach. Iced water will stimulate a more 
rapid and more copious secretion of gastric juice. Hot water 



IO THE USES OF WATER. 

will soothe an irritated stomach if taken into it before food is 
swallowed, and will help to cleanse it of mucus, bacteria, and 
remnants of food. When the stomach is secreting an in- 
sufficient amount of gastric juice, it is well to give a glass of 
iced water before or with an albuminous meal. If starches 
form the chief constituent of the meal, iced water should not 
be given, because the cold lessens salivary secretion and 
salivary digestion in the stomach. When an excess of gastric 
juice is formed a copious draft of hot water taken twenty 
minutes before a meal is beneficial. Ordinarily, drinking-water 
may be cooled, but should not be excessively cold. Iced water 
should not be taken when one is overheated. Many cases of 
gastro-intestinal derangement in summer are due in part, if 
not altogether, to the excessive use of cold drinks. 

If water is drunk during meals, it should be taken only when 
the mouth is empty, and in moderate quantity. Food which 
is only half masticated must not be washed into the stomach 
by drinking fluids. It is often best to drink water freely when 
digestion is at its height or has passed that point — say three 
or four hours after meals, especially if the stomach's contents 
is strongly acid. It will then help to wash the digested and 
disintegrated food from the stomach, and dilute the acids of 
the stomach so that they can be more quickly neutralized by the 
secretions in the duodenum. Mattil and Hawk 1 recently have 
studied experimentally the effect of drinking water at meal- 
times, and conclude that, if it is drunk when the mouth does 
not contain food, it does good. From one to two liters of 
water taken at meals caused fat, protein, starch and sugar to 
be absorbed more perfectly than when little water was drunk, 
doubtless because the gastric and pancreatic juices are increased 
and peristalsis is made more active. 

An important cause of constipation is a lack of sufficient 
fluid to keep the fecal matter soft. A mild grade of consti- 
pation can frequently be corrected by the drinking of one or 
two glasses of water, preferably hot, when the patient first 
leaves his bed in the morning, for it then stimulates peristalsis. 

Water is essential to the maintenance of good elimination. 
It is a most important diuretic and diaphoretic. In many 

2 Jnl. American Chemical Soc, Vol. XXXIII, No. 12, Dec, 1911. 



HYPODERMOCL YSIS . 1 1 

pathologic states, when the stomach will not retain water and 
when frequent, copious intestinal movements prevent its 
retention in the blood in quantities that make it diuretic, 
water can be advantageously administered hypodermically. 
This method is called hypodermoclysis. A pint or half-pint of 
sterile, ''physiologic" salt solution (i.e., 0.5 to i per cent, of 
sodium chlorid) can be introduced beneath the skin and will 
be rapidly absorbed and as rapidly eliminated. This is one of 
the most powerful diuretic measures that can be adopted. 
Water is also often given by the rectum when it cannot be 
taken by the stomach. A half-pint or pint of salt solution 
will be absorbed from the lower intestine. If the latter is 
irritable, small quantities only should be introduced into 
it. Unless the rectum be first emptied of its fecal contents, 
such enemata are of but little use, as they will not long be 
retained. In many cases, especially of bed-ridden patients, 
it is well to give a ''high" or ''colon enema" of salt solution 
by means of a tolerably thick soft-rubber colon tube, of as 
large caliber as can conveniently be used. Such tubes are 
less likely than smaller ones to kink or become bent back 
upon themselves when pushed through the rectum. 

Water or salt solution can be introduced also into the rectum 
drop by drop continuously. It is then very perfectly absorbed 
and its presence does not provoke expulsion. The water 
should be kept at a temperature of 98 to ioo° F. in a vessel 
about 18 inches above the patient. The rectal tube attached 
to it must have in it a stopcock so adjusted that it will deliver 
a drop in the rectum about once a second. This is the best 
method of administering large quantities of fluid constantly to 
those who need them. 

It is often said that to drink water copiously is fattening. 
Water does not contribute to the production of fat, but it does 
produce more rapid and better distribution of nourishment 
throughout the body than occurs when food is eaten and but 
little fluid is imbibed. To lessen fat-production it is best to 
diminish the quantity of food eaten and to modify, if need 
be, its character, but it is best not to lessen unduly or for many 
days the quantity of water consumed, because that will 
diminish the elimination of waste, salivary, gastric, and other 



12 THE USES OF WATER. 

secretions, and tend to promote constipation and other patho- 
logic states. 

Through the agency of drinking-water many harmful 
impurities are introduced into the body. These may be 
inorganic chemicals, such as lime, magnesia, iron, and other 
salts, or micro-organisms. Typhoid fever and cholera are 
chiefly disseminated by drinking-water. Therefore it is of 
the greatest importance that the water-supply of a community 
be free from organized and organic impurities. The inorganic 
ones do serious harm least frequently, but an excess of lime- 
salts may increase the tendency of certain individuals to develop 
renal calculi; and sulphates in abundance may produce 
annoying purgation. 

It is not only necessary that drinking-water shall be pure, 
but all that is used for cooking purposes and for washing 
dishes in which food is stored or cooked must also be pure. 
Not infrequently epidemics of typhoid fever have been traced 
to milk contaminated by water that contained typhoid bacilli, 
and that had been used to cleanse the cans in which the milk 
was stored. 

Water is best purified by distillation. Both organic and 
inorganic impurities can thus be removed. Micro-organisms 
can be killed by prolonged boiling. When water is boiled, 
the air is driven out of it and the organic matter in it is often 
partly decomposed which therefore makes is for the time 
being at least offensive. This odor is lost by prolonged boiling, 
for during the process the volatile impurities are driven off. 
Both distilled and boiled water has a flat, insipid taste, because 
the air has been expelled from it. It can be made palatable by 
forcing a current of pure air through it, or by pouring it from 
pitcher to pitcher or shaking it in a large bottle. In these 
ways water can be once more aerated. 

Filters will remove gross impurities from water. The best 
will eliminate even most of the micro-organisms. In the course 
of time, however, the filtering material becomes saturated with 
bacteria, which are finally washed through in very large 
numbers. Therefore filtered water cannot be so thoroughly 
depended on as distilled water; consequently when filters are 
used, great care must be taken to change or cleanse the filtering 



RAIN-WATER. 1 3 

substance frequently. The Pasteur or Chamberlain filter is the 
best. It will remove micro-organisms almost entirely from 
water. It is made of porous earthenware through which the 
water is filtered. The filter-tubes should be boiled frequently, 
to destroy all organized impurities in their pores. 

Numerous small stills are upon the market that are adapted 
to family needs. These are much more reliable purifiers of 
water than filters and are no more difficult to use. 

Waters are classified as soft or hard, according as they contain 
little, or no, or much, mineral matter in solution. 

Rain-water is soft and more nearly resembles distilled water 
than any other natural water. When rain first falls it absorbs 
from the air certain germs and volatile acids that are at times 
present in it. If rain-water is collected, as it usually is, from 
roofs, it will contain also dirt that has lodged upon them. 
For this reason it is best to permit the rain that falls during 
short showers and during the first few minutes of heavy ones 
to escape, and to collect only that which falls later. 

Certain spring-waters contain a minimum of mineral matter. 
The water of these springs does not pass through many strata 
of rock. 

Soft waters are the most wholesome for consumption, but 
they are not always the most palatable. Hard waters 
frequently are relished better. 

Mineral waters have been drunk for their medicinal effect 
since the savage days of man. Some have a pronounced 
physiologic action and others little or none. The benefit 
which invalids derive from a visit to a spa can rarely be 
obtained by drinking the same water at their homes. The 
freedom from care and hopefulness which absence from home 
generally insures, the change of diet, more exercise than usual 
in the open air are more important factors in influencing some 
cases than the mineral water. Invalids improve with so 
much greater certainty at the spa that many think the waters 
contain some volatile substance such as radium which is lost 
when the water is transported or stored. It is true that the 
latter element or some radioactive ingredient is found in many 
mineral waters. But how active therapeutically this agent in 
them is, has not been demonstrated. 



14 THE USES OF WATER. 

Artificial mineral waters are certainly not the same in effect 
as natural ones and probably not in composition. The latter 
contain traces of mineral matter which may help to make 
them more efficient. Moreover, they are formed under 
pressure and contain double salts. The difference in their 
physiologic effect is typified by the fact that more mineral 
matter is absorbed from them in a given time than from those 
artificially mineralized and water artificially charged with 
carbon dioxid gives off the gas much more rapidly than does 
that which is charged naturally. In the latter the gas is 
probably in loose combination which causes its slower escape 
and its less violent ebullition. 

Spring waters vary greatly in the degree of concentration 
of their mineral ingredients and in the relative amounts of 
them. The analyses of two waters may be alike in their 
ingredients and not very different in relative proportion of 
each, but one may contain twice or several times the amount 
of mineral matter that the other does. Moreover, the analyses 
of spring-waters vary a little from time to time but chiefly in 
the degree of concentration of the mineral matter in them. 

Spring waters are classified by their predominating ingredi- 
ents for they often contain other ingredients which, if they 
occurred in large instead of small quantities, would change the 
position of these waters in the classification usually adopted. 
The following is the best classification and is based on their 
chemical composition: 

Class I. — Alkaline: contains alkaline carbonates chiefly. 

Class II. — Alkaline- Saline ; contains in approximately equal 
quantities carbonates and chlorides. 

Class III. — Saline: contains chlorides in largest quantity. 

Class IV. — Chalybeate: contains salts of iron. 

A water in either of these may be described as sulphated or 
muriated according as sulphates or chlorides are next in degree 
of concentration to the predominant salt. They may also be 
either hot or cold and gaseous or plain. The gas in them may 
be carbon dioxid or sulphureted hydrogen. All of these varia- 
tions change the therapeutic properties of springs. For instance, 
much of sulphates in an alkaline water may make it purgative. 
A hot water is more soothing than a cold one. It often lessens 



SPRING WATERS. 1 5 

peristaltic activity and the rapid formation of gastric secretions. 
However, these effects are not very marked when water is 
drunk for it is so quickly reduced to body temperature. But 
cold water does stimulate the secretion of gastric juice. 

Carbon dioxide gas makes a table water more agreeable both 
to the eye and to the taste. It aids digestion by promoting 
chemical changes and muscular activity. It is also somewhat 
more rapidly absorbed than plain water. However, it should 
not be given to persons who are cyanotic or to those whose 
stomachs are dilated or to those whose hearts are weak and 
easily influenced in rate and regularity by gastric distention. 
Sulphureted hydrogen gas is not usually an active therapeutic 
factor in mineral water. It may be beneficial in catarrhal and 
in mild suppurative disorders of mucous membranes. Usually 
salts in solution in these waters are the most active therapeutic 
agents. 

The alkaline waters neutralize acids in the stomach, stimulate 
a more liquid and less mucous secretion from various mucous 
membranes, makes alkaline the urine and increases its amount. 
They are useful in catarrhal inflammation of the gastro- 
intestinal, biliary, respiratory and urinary tracts. The simple 
alkaline waters are used almost exclusively to neutralize acids 
in the stomach and to stimulate diuresis. When the chlorides 
appear in them in considerable quantity they become better 
solvents and diluents of mucus, and when the sulphates also 
occur in them in notable amounts they become mildly laxative. 
The latter are especially useful in gastro-intestinal catarrhs, 
gastric ulcer, catarrhal jaundice, congestion of the liver, 
cholelithiasis, gout and renal lithiasis. The following well- 
known waters may be regarded as types of the groups of 
acidulous waters or of those containing carbon dioxide : 



Simple acidulous, 



Alkaline acidulous 



Appolinaris. 

Geyser Spring, California. 

Manitou Soda, Colorado. 

Neuenahr, 

Salvator, 

Vals, 

Vichy, 

California Seltzer, 

Saritoga Vichy. 



i6 



THE USES OF WATER. 



Alkaline muriated acidulous 



Alkaline saline acidulous 



Ems, 

Seltzer. 

Saratoga, 

Roy at. 

Carlsbad, 

Marienbad, 

Keyser Spa, California. 

Castle Hot Springs, Arizona. 

Idaho Hot Springs, 

Manitou Springs. 

In saline spring waters chlorides or sulphates predominate 
sometimes together though often separately. In the chloride 
group of waters sodium chloride predominates but many other 
chlorides are commonly present in varying amounts. Bromine 
and iodin are sometimes present in these waters, usually in 
amounts so small as to make their therapeutic value doubtful 
but, when relatively abundant, the waters containing them 
have been found beneficial for the scrofulous and the syphilitic. 

The chlorides stimulate gastric, hepatic, intestinal and renal 
secretions. The waters containing them have been found bene- 
ficial in chronic gastritis especially of the mild type and often 
in exacerbation of the alcoholic type. When spring waters 
contain these ingredients in considerable quantity they are 
mildly aperient. They are preferred to the bitter waters in 
the portal congestion of thin people who cannot stand much 
reduction in weight. They are also often prescribed as an 
expectorant by those having chronic bronchitis. 

The bitter waters contain magnesium sulphate or sodium 
sulphate or both in large quantity. When these waters are 
concentrated they are vigorous purgatives. They also stimu- 
late the secretion of bile and urine. Therefore they are bene- 
ficial in cases of chronic constipation in which there is enlarge- 
ment of the liver and often a subicteric staining of the conjunc- 
tiva and skin. The presence of chlorides and alkalies make 
some of this group of waters more beneficial. Sulphureted 
hydrogen exists in many of these spring waters. When the 
mineral matter is at all concentrated in them they are bitter and 
sometimes nauseous. This necessarily limits their usefulness. 

The following are among the well-known chlorid saline 
springs: Eureka Springs, California; Magnetic Mineral Spring, 



SPRING WATERS. 1 7 

Indiana; Blue Lick, Kentucky; Mount Clemans, Michigan; 
Congress, Saratoga; Glenwood, Colorado; Harrowgate, England; 
Baden Baden, Hamburg and Wiesbaden, Germany; and 
among the well-known sulphate saline springs are: Crab 
Orchard, Kentucky; Bedford Springs; Apenta; Hunyadi Janos 
and Kissingen. 

The chalybeate springs contain iron in the form of bicarbon- 
ate, oxide, sulphate or chlorid. Of these the first, especially 
if it is combined with other carbonates and contains carbon 
dioxid, is the best and most agreeable to take. The fact that 
only small amounts of iron are contained in these waters does 
not make them less useful in the treatment of anemias. The 
springs which contain iron in the form of sulphates often also 
contain alum and arsenic and are particularly useful in diarrheas 
and in the anemias due to them. Usually these waters must 
be drunk in small amounts otherwise they will produce indi- 
gestion. Franzenbad, Richfield, Cresson and Rawley, Vir- 
ginia, are types of the carbonated chalybeate springs. Sharon 
chalybeate and Bedford alum are types of the sulphated alum 
group. 

As the active ingredients of waters vary in amount in different 
springs the quantity to be drunk varies at each and also varies 
with the nature of each patient's disorder. Spring waters to 
be effective therapeutic agents must be given with the same 
care and judgment as other medicine. 

When properly used and especially when drunk at the spring, 
mineral waters will be found to be most important remedial 
agents and ought not to be neglected. 



CHAPTER III 

THE ELEMENTS OF FOOD 

Proteins — Digestion, Assimilation, Elimination; Effects in Health 
and Disease. Fats and Oils — Uses; Digestion and Assimilation; 
Effects in Health and Disease; Butter; Cream; Cod-liver Oil. 

PROTEINS 

Proteins have both an animal and a vegetable origin. They 
form so large a proportion of animal food, however, and so 
small a proportion of vegetable food that the former is their 
chief source. They are composed of carbon, hydrogen, nitrogen, 
oxygen, and sulphur, which are united to form a very complex 
molecule. 

The first step toward the digestion and utilization of proteins 
is mastication, by which the food is broken and roughly dis- 
integrated and lubricated with mucus, while some of the salts 
in it are dissolved. Unless mastication is thoroughly performed 
when meat — pre-eminently protein food — is eaten, its further 
disintegration and digestion by the stomach will be slow, and 
in pathologic states may be painful. Cooking is of importance in 
preparing meats for easy digestion, for by it the connective 
tissues are converted into gelatin, which readily dissolves in 
the gastric juice and permits the rapid separation of cell from 
cell. 

Hydrochloric acid is the essential acid of the stomach, and its 
presence is necessary for the proper digestion of proteins. Meat 
and bouillon rich in meat extractives are the best stimulants to 
the formation of hydrochloric acid by the glands of the stomach. 
Acids taken before a meal of meat will hinder the formation of 
gastric juice and are to be deprecated at this time. If taken at 
the end of the meal, they are not harmful. 

18 



DIGESTION OF PROTEINS. 1 9 

The normal churning movements of the stomach are most im- 
portant in order to facilitate the commingling of food and gastric 
juice so that digestion may progress as rapidly as possible, and 
to transfer what has been well disintegrated or digested into the 
intestines. Many cases of functional derangement of digestion 
are due primarily to slow and imperfect movements of this 
organ. Impaired mobility is also an important factor of in- 
digestion when there is structural disease of the organ. A 
sedentary life and reduced muscular strength and nervous 
energy from any cause will lessen the activity of the stomach. 
Although its churning movements are altogether involuntary, 
they are much influenced by emotional excitement, especially 
when great or prolonged. Distress, anxiety, sorrow, and fear 
will often check digestion for the time being. 

The first chemical change that proteins undergo in gastric 
digestion is the conversion of a part of them, by means of the 
hydrochloric acid that the stomach's juice contains, into acid 
albumin. Under the influence of pepsin the latter is still 
further transformed by several changes into a series of proteoses, 
and finally into the terminal product, peptone. 

Peptone is absorbed from the stomach in comparatively small 
quantity. Most of it, together with the proteoses and the pro- 
teins, as yet undigested, is emptied into the duodenum. Here 
the acidity of the stomach-contents is neutralized, and protein 
digestion is completed under the influence of the pancreatic 
ferment, trypsin. 

Trypsin is formed in the small intestines from trypsinogen 
which is excreted by the pancreas in its juice or secretion. A 
ferment secreted by the glands of the intestines called entero- 
kinase converts inactive trypsinogen into active trypsin. The 
intestinal glands also secrete erepsin, a ferment which splits 
peptones into aminoacids and ammonia. 

In the intestine, proteins that have not undergone digestion in 
the stomach are first transformed into alkali albumins, then 
into proteoses, peptones, polypeptids and amino acids. The 
proteoses and peptone that come from the stomach are also con- 
verted into antipeptone and amino acids. The following 
diagram will make these processes clearer: 



20 THE ELEMENTS OF FOOD. 

Stomach Digestion. Intestinal Digestion. 

Proteins ► Proteins 

(by HC1) (by tryspin) 

1 I 

Acid Albumin Proteoses 
(by Pepsin) 

4 1 

Proteoses Peptones 



I 
I 

Peptones (by erepsin) 



1 
J Polypeptides 
\ Amino acids 



It is uncertain whether the products of protein digestion are 
absorbed as polypeptids or amino acids or both. Certainly 
the latter finds its way to some extent into the portal vessels. 
It is doubtful if the epithelial cells of the intestine synthesize 
the products of digestion into the albumens of the blood as was 
once supposed, certainly they do not do so completely. Syn- 
thesis takes place probably in every cell of the body, the amino 
acids brought to them by blood and lymph or possibly formed 
by their disintegration being utilized for cell production. 
Moreover, it is known that the products of protein digestion are 
transformed in part at least into nitrogenous derivatives which 
may be eliminated as such and into nonnitrogenous derivatives 
which may be utilized for the production of energy or stored as 
fat or glycogen. 

The nitrogenous derivatives are ultimately eliminated by 
the kidneys as urea, ammonia and purin bodies. Urea the 
form in which they are mostly eliminated is produced in the 
liver from ammonia made in the tissues and brought to that 
organ by the blood as a carbonate. Imperfect functional 
activity on the part of the liver causes a relatively large amount 
of ammonia to be eliminated by the kidneys. Pathologic 
conditions such as fever and diabetes also disturb the relative 
proportion of these substances in the same way by forming 
acids during metabolism which produce stable ammonium 
salts. Normally 2 to 6 per cent, of the total nitrogen elimi- 
nated by the kidneys is in the form of ammonium salts. The 
purin bodies including uric acid are formed from nucleoprotein. 
From 0.3 to 0.4 grams per day is produced by metabolism of 
the tissues; the remainder from nucleoprotein in food. The 



On High 


On Low 


Protein 


Protein 


Diet 


Diet 


Grams 


Grams 


16.8 


3.6 


14.7 


2 . 2 


O.49 


0.42 


0.18 


0.09 


0.58 


0. 60 



FERMENTATION OF PROTEINS 21 

amount of nitrogenous excreta varies with the diet as is shown 
by this table modified slightly from Sherman. 1 



Total nitrogen 

Urea 

Ammonia. 

Purins, etc. 

Uric acid 

Creatinin 

Undetermined 0.85 0.27 

The acidity of the contents of the small intestine is due to the 
acids derived from the stomach and to organic acids formed 
from fats in the intestine. As these are in part absorbed, and in 
part neutralized by the secretions normally poured into the 
intestine, the contents grow less acid and often become alkaline 
very quickly. 

In both the stomach and the intestine bacteria cause more or 
less putrefaction or abnormal fermentation of foods. Among 
the compounds thus formed from proteins in the intestines, 
indol and skatol are especially well known. They are produced 
most abundantly when protein digestion is slow or ceases, and 
when proteins remain undigested and unabsorbed for a long 
time in the intestine. Therefore, disturbances of pancreatic 
secretion and imperfect or very slow peristalsis are conditions 
that contribute to their formation. The discovery of these 
substances in the urine in unusually large quantities is indicative 
of such disturbances of protein digestion. 

The movements of the intestines, or peristalsis, are quite as 
essential to rapid digestion of food in them as are the churning 
movements of the stomach. As the food is moved through the 
intestine its digestion is completed and it is absorbed. 

Normally the products of protein digestion are not absorbed 
from the stomach. Most of them are absorbed from the small 
intestine ; probably more than 80 per cent, is taken up by its 
villi. 

1 Chemistry of Food Nutrition, by H. C Sherman page 116. 



22 THE ELEMENTS OF FOOD. 

Inflammation of the intestines often hinders or prevents 
absorption. This will necessarily interfere with the mainte- 
nance of strength and flesh. Disturbances of circulation, de- 
struction of epithelium, the obstruction of lymph-spaces with 
inflammatory exudates, and the formation of a covering of 
mucus, all take part in the causation of such an interference 
with absorption. 

Pathologic processes sometimes give rise to the appearance of 
peptone in the urine. Often, they prevent, as in fevers, for 
example, the appropriation of food by tissue cells. When this 
happens, the cells can no longer develop a normal degree of 
energy, and may waste, atrophy, or die. 

Meat is the chief source of proteins. Beefsteak, for example, 
contains 20 per cent, of it. In foods of vegetable origin a 
variable amount is found. For instance, bread contains 8 per 
cent. ; arrow-root, 0.8 per cent. ; potatoes, 2 per cent. ; and dried 
peas, 22 per cent. Although dried peas are as rich in proteins 
as is beefsteak, they contain only 2 per cent, of fat and 53 per 
cent, of carbohydrates, while the flesh contains 3.5 per cent, of 
fat and no carbohydrates. 

If meat be the chief food consumed by a man, the quantity of 
urates, urea, phosphates, and sulphates in his urine will be 
increased. Animal food requires a considerable quantity of 
oxygen for its utilization by the tissues. Therefore, a diet 
composed largely of meat increases the demand for oxygen. 
Most persons are more energetic and active when they eat 
meat freely than when they live chiefly upon vegetables. But 
if digestion is disturbed, or if there is a tendency to gout, this 
is not the case. Meat better satisfies hunger than will the 
same bulk of carbohydrate food. It is very agreeable to most 
persons, and its aroma and flavor stimulate appetite and 
gastric secretions. For these reasons most persons are tempted 
to eat too much meat. If, by an abundance of outdoor exercise, 
sufficient oxygen is not furnished to utilize it and a need for 
it is not also thereby created, an excess of protein waste will 
accumulate in the blood and tissues and cause biliousness, gout, 
and other disorders. 

Meat is not a necessity of life. Nitrogenous food is a neces- 
sity, but it can be obtained in sufficient quantities from vege- 



QUALITY OF PROTEIN NEEDED 23 

tables, certainly from vegetables supplimented by milk and 
eggs. An exclusively vegetable diet will enable a person to do 
as much, and at times even more work, as a diet containing an 
excessively large amount of meat, but it will not fit one as well 
to meet sudden demands for great exertion. A mixed diet is 
undoubtedly the most desirable : but one that contains a very 
moderate amount of meat is best. A diet rich in meat and 
relatively poor in carbohydrates is less fattening than one 
with these conditions reversed. 

When carbohydrates and fats are eaten abundantly less 
protein is required to maintain a protein balance than when 
less is taken, therefore, they are called protein savers. Exercise 
or muscular work does not increase the breaking down of tissues 
in proportion to its increase, on the contrary muscles grow 
larger by use not smaller, therefore there occurs an appro- 
priation and storage of nitrogen from protein food. There is, 
however, enough protein in an ordinary mixed diet always to 
supply this need. 

How much protein is required to maintain health when an 
abundance of fuel in the form of carbodydrates and fat is eaten 
is a problem which has long vexed dietitians and physiologists. 
Voit observing the habits of large numbers of individuals con- 
cluded that 118 grams of protein were needed. Playfair recom- 
mended 1 19 grams, Gautier 107 and Atwater in our own country 
150 for a man at hard work and 90 to 100 when at rest. More 
recently Chittenden has studied the subject exhaustively. By 
practical experiments on groups of men following different 
vocations and doing various grades of work, he found that they 
remained in good health, were well nourished and strong on a 
diet which afforded an average of 50 grams of protein and 
enough of other foods to supply the needed energy. Therefore 
he concludes that the old standards are much larger than they 
should be. This is doubtless true at least in adult life. In- 
fants get in the milk which is their only food an amount of 
protein which would be equivalent to 140 grams for an adult. 
But it must be remembered that their cells are multiplying 
with rapidity and for this a large amount of protein is needed. 
As a child develops into manhood or womanhood gradually 
less is needed. 



24 THE ELEMENTS OF FOOD. 

FATS AND OILS 

Sources of Body Fat 

Twenty per cent, of the normal weight of the average man is 
fat. It is, however, only in small part derived from fatty food. 
Its chief source is carbohydrate food. Proteins also produce a 
part of it. 

Uses of Body Fat and Fat Food 

Most of the fat that is eaten is rapidly oxidized and supplies 
much of the heat generated by the living body. Because it is 
so rapidly utilized for heat-production it saves the living tissues 
in part from waste. It also contributes a little to the formation 
of tissues. Tissue waste is most rapid under a protein diet. For 
these reasons a moderate ingestion of fatty foods makes it 
unnecessary to eat so large a quantity of protein as would 
otherwise be needed to furnish energy and contribute to the 
growth and repair of tissues. Fat is, therefore, sometimes said 
to be a protein saving food. 

The accumulation of fat in the tissues has little to do with the 
ingestion of it. It is in them a store of potential energy, and 
may be drawn upon when the food supply is deficient or de- 
fective. When present in the subcutaneous tissues it gives 
rotundity and often beauty of form, both of which are absent 
when the muscles are unpadded. It also preserves the heat of 
the body by preventing too rapid cooling. 

Digestion of Fatty Food 

When eaten, fat undergoes no digestive change in the mouth 
but when it is taken in the form of a fine emulsion, as in milk 
and yolk of egg f a ferment formed in the stomach can split 
it into its components. When it occurs in cooked meat, it is 
set free in the stomach in the form of large oil globules, because 
the gelatinized connective tissue that holds it is then dissolved. 
In certain forms of indigestion it is decomposed in the stomach 
and fatty acids are set free. They are irritating to the viscus, 
and may excite local inflammation. Such decomposition is 
due to the growth of certain micro-organisms that enter 
the stomach with the food. It is in the intestines that 



DIGESTION OF FATS. 25 

fats and oils are modified by digestion and are prepared for 
absorption. The pancreatic ferment steapsin decomposes 
them into fatty acids and glycerin. The presence of fatty acids 
in the small intestine gives its contents a faintly acid reaction, 
although the first effect of the alkaline secretion of the intestine 
is to neutralize the acids of the chyme from the stomach. 
Formerly it was taught that the fatty acids help to facilitate 
the emulsification of the remainder of the oils and fats of the 
food, and that from the bile, pancreatic juice, and succus enter- 
icus an abundance of sodium carbonate is obtained. The 
sodium unites promptly with the fatty acids to form soap, and 
carbonic acid gas is set free. The soaps thus formed, and the 
agitation that intestinal peristalsis gives to the contents of the 
alimentary canal, afford the conditions needed for the making 
of an emulsion in which form is was believed to be absorbed into 
the lacteals. Sodium makes, with fatty acids, soluble soaps, 
but magnesium and calcium also form soaps in the intestines 
that would be almost insoluble were it not for the bile, which 
is able to dissolve them. It is now believed that most of the 
fat in the intestines is split into glycerin and fatty acids 
and the latter is held in solution by the bile. 

In pathologic states, when bile is secreted in insufficient 
quantity or its entrance into the intestines is prevented by a 
calculus or other obstruction of the common bile-duct, fatty 
acids are very imperfectly dissolved and most of the fat then 
eaten appears in the stools saponified or undigested. When 
the pancreatic juice is deficient or absent, the same disturbance 
of digestion is observable. Inflammation of the duodenum 
may also delay fat digestion, but not to the same extent as 
results from the failure of bile or pancreatic juice to reach the 
intestine. 

Fats are not absorbed until they reach the intestine, and are 
taken up almost exclusively from the small intestine, the wall 
of the large bowel absorbing an inconsiderable quantity. The 
epithelial cells covering the villi of the intestine play an im- 
portant part in the absorption of fat. Fatty acids and glycerin 
are taken up by these cells and are recombined by them into 
fat granules, which are excreted in turn into the lacteals. The 
abdominal lymphatics collect the fat thus properly synthesized 



26 THE ELEMENTS OF FOOD. 

for the use of the human body and finally empty it into the 
general blood-current. 

The fat in the blood is oxidized chiefly in the most actively 
metabolic tissues of the body. Possibly a small amount may 
be oxidized in the blood itself, and another small amount may be 
deposited as reserve in fat tissues. It might be supposed that 
the epithelial cells of the intestines when they recombine fatty 
acid and glycerin would fashion the fat into that peculiar to the 
body of which they are a part, but this is not altogether true, for 
when rapeseed oil and mutton tallow which can be easily de- 
tected have been fed to animals, they have been recovered 
again from the fat stored by the animals in their own tissues. 
The end-products of fat metabolism are carbonic acid and 
water; these are excreted by lungs, skin, and kidneys. 

Butter and cream are the most agreeable forms of fatty food. 
Bacon, when hard fried, is digestible and well relished by many 
persons. Cod-liver oil is not agreeable, although a fondness for 
it is sometimes acquired. It is, however, easily digested. 
Even if one does not become fond of this oil, he soon learns to 
tolerate it. 

Of fat meats, fat pork is least digestible and fat mutton is less 
digestible than fat beef. 

Artificial emulsifi cation has been resorted to in order to make 
fats and oils more digestible. It is doubtful if such emulsions 
accomplish their purpose. Certainly the cruder ones, made by 
mechanical processes or by simple suspension of an oil in fluids 
thickened with gum arabic, sugar, and other viscid substances, 
do not aid digestion. An emulsion made with pancreatic 
extract may do so. 

Too much fat in the food leads to abnormal production of 
fatty acids and consequent indigestion. Of all common articles 
of food, fat must be used most sparingly and most judiciously. 

Fats and oils are especially to be limited in amount whenever 
one has indigestion. They are likely to cover the mucous mem- 
brane of the stomach and particles of food, and so to hinder 
secretion by the peptic glands and interfere with the attack of 
foods by the gastric juice after it is formed. 

When digestion is good, a limited quantity of fat can be 
digested and is most wholesome. Satiety is reached more 



USEFULNESS OF FATS. 27 

quickly by its use in increasing amounts than by protein or 
carbohydrate foods. In general, animal fats are better toler- 
ated than vegetable oils. Hot fats are usuallly less digestible 
than cold fats. For this reason many persons find it difficult to 
eat hot mutton and pork, but digest them when eaten cold. 
Fried foods are not so digestible as foods cooked in other ways, 
and should be forbidden absolutely for invalids, and but rarely 
be employed by persons in good health, as these foods are 
difficult of digestion, and thus lead to dyspepsia and even to 
disease of the digestive tract. All fats, except limited quanti- 
ties of butter and cream, should be forbidden in acute diseases 
of the stomach, intestines, and liver, and in most of the chronic 
ones. Their use should be closely limited in the presence of 
gall-stones and when there is a tendency to acne or urticaria. 

On the other hand, fatty food must be prescribed for children 
with rickets and for all who have diabetes. In the latter disease, 
it partly replaces the carbohydrates, which cannot be used. 
Fat may be prescribed with benefit in chronic wasting diseases, 
such as tuberculosis, and during convalescence from severe 
acute diseases. The most agreeable and digestible forms should 
be used. At first small portions only should be taken and the 
quantity be increased as tolerance is acquired. 

In a general way fats and oils are laxative, and consequently 
are useful for those who are constipated, and equally harmful 
for those who have a tendency to diarrhea. 

Most articles of food contain a varying amount of fat and oil. 
For instance : 

Pork (salt) contains 82.8 per cent. 

Bacon contains 69 . 5 per cent. 

Beef contains 27.0 per cent. 

Milk contains 4.0 per cent. 

Beans contain 2.0 per cent. 

Potatoes contain o . 1 per cent. 

Oatmeal contains 7.1 per cent. 

Cornmeal contains 3.8 per cent. 

Peas contain 1.7 per cent. 

Butter contains 85.0 per cent. 

The animal fats most commonly used, aside from what is con- 
tained in meats, are butter, cream, eggs, lard, suet, tallow, 



28 THE ELEMENTS OF FOOD. 

oleomargarin, butterin, and cottolene. These may all be used 
in cooking or as adjuvants to foods, but they must be employed 
sparingly by most persons. The vegetable fats that are most 
used are olive oil, cotton-seed oil, linseed oil, cacao-butter, the 
oils of various nuts, especially cocoanuts, peanuts, and almonds. 
Cod-liver oil not only is a food, but contains some medicinal 
properties, probably chiefly due to the iodin and other inorganic 
elements that it contains; and possibly also to certain organic 
derivatives of the liver that resemble alkaloids. Cod-liver oil is 
used whenever it is desirable to administer fats in as large an 
amount as possible, and when only the most digestible forms can 
be given. A tolerance of it is soon acquired by children, even 
by infants. Adults are rarely able to take it in sufficient quan- 
tities to make its use of much importance. It is given to adults 
in doses of one or two tablespoonfuls three or four times daily, 
commencing with much smaller doses. To disguise its taste it is 
frequently given as an emulsion that is flavored with winter- 
green and other aromatic oils, or it is mixed with malt extracts. 
If the taste is disagreeable, it is best given in elastic capsules. 
The clearest oils are the best and are most easily taken. A pinch 
of salt taken before and after the oil often makes it palatable. 
It can also be floated in strong coffee or peppermint water, and 
so swallowed as scarcely to be tasted. Preferably it should be 
taken clear and swallowed quickly ; a little salt or a dry cracker 
may be eaten afterward to remove the taste from the mouth. 



CHAPTER IV 
THE ELEMENTS OF FOOD (Continued) 

Carbohydrates — Composition; Digestion; Abnormal Fermenta- 
tion; Absorption. Action of Liver. Utility in Health and Dis- 
ease. Interrelationship of Foods. Effect of Changes of Diet. 
Salts. 

CARBOHYDRATES 
Composition 

Carbohydrates are composed of carbon, hydrogen, and oxy- 
gen. The most important are starch, sugar, and cellulose. 
Chemists recognize three main divisions: (i) Polysaccharides, 
or starches, cellulose, dextrin, and gums; (2) disaccharides, such 
as cane-sugar, lactose, and maltose; (3) monosaccharides, which 
include dextrose, or grape-sugar, and levulose, or fruit-sugar. 
Carbohydrates are eaten chiefly in the form of starch and cellu- 
lose, but must be transformed into dextrose, or grape-sugar, 
before they can enter the blood and contribute to the main- 
tenance of bodily vigor. 

Digestion 

Starch occurs in the form of grains or small particles with a 
nondigestible envelope of cellulose about them. When, in cook- 
ing, it is subjected to heat and moisture, it swells, and the 
envelope ruptures, permitting the starch grains to escape. 
Therefore, in order that starch may be digested, cooking is 
essential. If starch, cereals, and vegetables are cooked 
imperfectly they are indigestible. When, after cooking, 
starch is taken into the mouth, the granules are, by masti- 
cation, more completely broken up and are incorporated 
with saliva so as to form a paste-like mixture. The thorough 
commingling of saliva with the starch is essential to good sal- 
ivary digestion. Ptyalin, the digestive ferment of saliva, splits 
starch first into various dextrins and ultimately into maltose, 
which is the end-product of its digestion. These changes are 
only begun in the mouth, as food is rarely retained in it more 
than a few seconds, or one or two minutes at the longest. A 

29 



30 THE ELEMENTS OF FOOD. 

comprehension of the process of salivary digestion makes evi- 
dent the necessity of perfect and slow mastication. Although 
salivary digestion progresses best in a slightly alkaline or neu- 
tral medium, it can take place in a faintly acid mixture also. 
Therefore it is chiefly continued in the stomach before the 
contents of the latter become strongly acid. It is supposed 
to be checked by the end of the first half-hour or three-quarters 
of an hour of gastric digestion. As starches usually form a 
large part of our meals, it is impossible to convert much of 
them into maltose while they are in the stomach. By the end 
of the period of gastric digestion some starch is undigested in 
the stomach, much of it is converted into various dextrins, and 
a little into maltose. The churning movements of the stomach, 
as well as the process of salivary digestion, help to disintegrate 
and dissolve the starch clumps that are swallowed, so that they 
will be emptied into the duodenum in a state of fine division 
and suspension, if not of solution. 

Such cane-sugar, milk-sugar, or fruit-sugar as is eaten is also 
partly digested in the mouth and stomach. When grape-sugar 
is eaten, it undergoes no digestive change. 

As already explained, salivary digestion in the stomach is in- 
fluenced by cooking and by mastication. The body-tempera- 
ture especially promotes its progress. Ice, iced food, e.g., ice- 
cream, and iced water will hinder the formation of saliva and 
lessen the activity of ptyalin digestion. Very cold drinks at 
the beginning of a meal or with it are therefore not favorable 
for starch digestion in the stomach. Starch in cold foods, such 
as potato salads, cold oatmeal mush, and similar articles, is not 
readily transformed in the stomach and should be eaten only 
by those whose digestion is good. However, the chief changes 
that starch-containing foods undergo in the stomach are 
disintegration and comminution of the masses in which they are 
swallowed, and a very moderate degree of chemical alteration. 

Salivary digestion is also delayed by eating, at the beginning 
of a meal, very acid fruit or food, which will rapidly acidify the 
contents of the stomach. Oranges and other acid fruits are 
therefore not so wholesome when eaten at the beginning of a 
meal as at the end. If fruit is eaten before breakfast, it should 
preferably be a sweet fruit or a compote. 



DIGESTION OF CARBOHYDRATES. 3 1 

When the digestion of starch in the stomach is imperfectly 
performed because of an excess of acid gastric juice, it may often 
be aided, if a glass of hot water is taken twenty or thirty min- 
utes before eating, in order to lessen the secretory activity of 
the stomach and to dilute partly its juice. If only carbohy- 
drates are eaten at one meal and only proteins at another, 
gastric digestion is often improved. 

Carbohydrates are chiefly digested in the intestine. Amyl- 
opsin, a pancreatic ferment, is essential to this process. The 
changes that it effects in starch are similar to those wrought 
by ptyalin. Maltose is again its end-product. Several dex- 
trins are formed in the progress of the final transformation of 
starch. Dextrins, cane-sugar, milk-sugar, and grape-sugar 
also find their way into the intestine. The first of these is 
modified by amylopsin and converted into maltose. 

Maltose is the final product of all carbohydrate digestion. It 
does not enter the blood, but is still further transformed into 
dextrose, either by the invertase of the intestinal juice, or possi- 
bly by the epithelial cells of the villi. Dextrose is the only 
carbohydrate found in the portal blood. 

Abnormal Fermentation 

When the digestion of carbohydrates is slow or ceases, 
bacteria and yeasts give rise to abnormal fermentation. Bac- 
teria are probably always active to some extent in the small 
intestine, and when carbohydrate food is eaten in quantities so 
large that it cannot readily be disintegrated by salivary 
digestion and the muscular activity of the stomach, it is certain 
to be a nidus for their growth. Potatoes, fried or stewed, and 
swallowed in chunks, will be slow to disintegrate. Fresh hot 
breads usually form masses of dough in the stomach that can- 
not well be broken up. A large meal of pancakes and syrup 
will be imperfectly prepared by the stomach for digestion, 
partly for the same reason that hot breads are, and partly 
because the excess of sugar that is eaten overtaxes the digestive 
powers of the organs. These articles of food at the tempera- 
ture of the body, and mingled with the other contents of the 
stomach, are especially favorable media for the growth of 
numerous micro-organisms. 



32 THE ELEMENTS OF FOOD. 

The results of bacterial fermentation of starches and sugars 
are ethyl alcohol, acetic, lactic, butyric, and succinic acids, 
carbonic acid gas, and hydrogen. Cellulose, when decomposed, 
forms marsh-gas and carbonic acid gas. The flatulence and 
meteorism characteristic of many dyspeptic states are due chiefly 
to the copious generation of these gases. When carbohydrate 
food rich in cellulose is fermented, it is especially productive of 
gases. Sugars are more likely to produce an excess of lactic, 
butyric, and acetic acids and a moderate amount of carbonic 
acid gas. 

Bacterial fermentation usually lessens from the beginning 
of the small intestine to its end. When excessive, it continues 
in the colon. Gases in the small intestine give rise to rumbling 
noises — borborygmi. These gases rarely find their way into 
the stomach. They may be passed from the anus, or may in 
part be absorbed. 

An idiosyncrasy present in certain persons is an inability to 
digest much carbohydrate food. Fever lessens the activity of 
all digestive processes and increases the tendency to abnormal 
fermentation. Most chronic diseases that produce great weak- 
ness have a similar effect. 

Absorption 

Carbohydrates are absorbed almost exclusively from the 
small intestine. A very small amount may be taken up by the 
walls of the stomach and the large intestine. Cane-sugar and 
milk-sugar are readily absorbable, but must undergo changes 
before they can enter the blood. Their conversion into dex- 
trose may occur in the epithelial cells or be produced by inver- 
tase in the succus entericus. 

These processes may be interfered with by extensive 
inflammation of the small intestine and by those maladies that 
are characterized by frequent profuse watery stools. 

Action of Liver 

The blood in the portal vein may contain as much as 0.3 per 
cent, of dextrose, but the blood that leaves the liver and enters 
other tissues of the body does not contain more than 0.1 per 
cent. It is evident, therefore, that much of the carbohydrate 
food that is eaten is arrested by the liver before it is distributed 



UTILITY OF CARBOHYDRATES. 33 

to the other tissues. The dextrose of the portal vein does not 
remain in that form in the liver, but is transformed into com- 
paratively insoluble glycogen. Glycogen is derivable to a small 
extent from fat and proteins, but carbohydrates are its chief, 
almost its exclusive, source. Sugar is retained in the liver as 
glycogen only temporarily. The organ contains an amylolytic 
ferment that converts it again into dextrose, in which form it 
is found in the general circulation. Glycogen is also formed 
and stored to a limited extent in muscles. 

Utility 

Dextrose is utilized by the metabolic tissues for the liberation 
of energy. Whether this is accomplished in the blood or in the 
lymph when it is in contact with active cells, or whether 
it must first be absorbed by, or form part of, the cells, has not 
yet been established though most physiologists to-day believe 
that it is accomplished outside the cells by a ferment which is 
made active by something derived from the pancreas. When 
metabolized, the waste is eliminated chiefly by the lungs as 
carbonic acid gas and water. 

All the dextrose in the general circulation is not used for the 
creation of energy; a part of it is stored as fat in the connective 
tissues. It is. put away, as it were, as a reserve of potential 
energy. 

Pavy contends that many protein molecules contain a carbo- 
hydrate element, and that albuminoid matter can be split into 
protein and carbohydrate matter or, it may be said, better into 
a nitrogenous and nonnitrogenous portion. This takes place 
apparently when, in certain diabetics, the ingestion of food has 
ceased, glycogen has been consumed, and still sugar is excreted. 
He claims that from 45 to 60 per cent, of the protein molecules 
is thus transformed into sugar. Not only can albuminoids be 
decomposed into protein and carbohydrate elements, but also a 
synthesis can be effected and part of the ingested and absorbed 
carbohydrate goes to form protein molecules. 

In diabetes there is a disturbance of dextrose metabolism that 

permits it to accumulate in the general circulation until it 

exceeds the normal 0.1 per cent., when it is eliminated by the 

kidneys. Individuals are peculiar as to the ease with which 

3 



34 



THE ELEMENTS OF FOOD. 



they store dextrose as fat. There are many who accumulate 
fat even upon a poor diet, and many who remain thin upon a 
habitually generous one. These variations become pathologic in 
cases of obesity and of excessive emaciation. Emaciation does 
not necessarily mean an inability to form fat from carbohy- 
drates. The fault lies often in the digestive organs, where food 
is not properly prepared for absorption or is not retained; or 
the dextrose that is absorbed is consumed in the production of 
heat, as in fevers. 

Interrelationship of Foods 

The interrelationship of proteins, fats, and carbohydrates is 
well illustrated by the following diagram. The ability of each 
to replace measurably one or both of the others is also shown. 
When proteins are eaten they are in part transformed into tis- 
sue, in part directly catabolized, and in small part transformed 
into carbohydrate matter and fat. When fats are eaten they 
are in small part stored in the tissues as fat ; in large part they 
undergo combustion directly. A part of the stored fat of the 
system that may be consumed in case of need is derived from 
the proteins and carbohydrates. Carbohydrates for the most 
part undergo direct combustion. 

Physiologic Interrelationship of Foodstuffs 



Fats 










Stored fat 



Carbohydrates 



Proteins 




Eliminated 



It is evident from this that proteins can very imperfectly 
replace the functions of fat and carbohydrate. Fat and carbo- 
hydrate are closely related in function and may in large degree 
replace each other, but neither can perform the special func- 
tions of proteins. 



PECULIAR DUCTS. 35 

Vegetarianism 

Those who live chiefly upon cereals, vegetables, fruits, and 
nuts are called vegetarians. These foods are with rare excep- 
tions supplemented by such animal food as milk, cheese, and 
eggs. A menu made up of these foods can be so planned as to 
supply both the carbohydrates, fats, and proteins that are 
needed. A part of the protein is derived from milk and eggs, 
and a part from the vegetables eaten. The nitrogenous matter 
obtained from vegetables is less easily digested than that which 
is of animal origin; a much larger percentage passes from the 
alimentary tract unutilized. Few persons live entirely upon 
a vegetable diet. Those who attempt it lose vigor and show 
languor and disinclination for physical and mental work. They 
become less able to resist disease. Because a vegetable diet is 
an economical one, it has sometimes been forced upon bodies of 
laborers, but uniformly the decrease in the amount of work that 
they are able to perform more than counterbalances the de- 
creased expense of their food. 

In vegetables enough protein can be found to make it possible 
to substitute them for meat for the purpose of maintaining life 
and strength. As vegetable protein is very imperfectly digested 
and absorbed, a sufficient vegetable diet must be a very bulky 
one. It will maintain strength, and by eating vegetable food 
only one may be able to lift as much ; but one will not be able to 
work so fast as on a mixed diet. He will lack energy and 
alertness. 

It is quite evident, from man's anatomic structure, physio- 
logic functions, and habits of eating, handed down from the 
earliest times, that a mixed diet is best adapted to his needs. 
At the same time it is unquestionably true that too much meat 
is ordinarily eaten by many individuals. 

Effect of Changes of Diet 

Often a change from a generous mixed diet to a so-called 
vegetarian regimen improves the health of individuals. It 
does this chiefly by correcting bad habits, such as eating too 
much, eating rich foods, drinking little; and by removing such 
pathologic states as constipation. A radical dietetic change 
usually diminishes a person's appetite, for fewer things that he 



36 THE ELEMENTS OF FOOD. 

enjoys are placed before him. The vegetables, fruits, and 
cooked cereals contain a larger amount of water than may 
otherwise be obtained. The coarser cereals, such as bran bread 
and fruits, as well as the increased supply of water, help to 
provoke more regular and copious bowel movements. 

SALTS 

The mineral ingredients of the body are essential to the main- 
tenance of life, to give the body form and stability, and to main- 
tain numerous special functions. Doubtless they take large 
part, by so-called catalytic action, in the more recondite 
chemistry of cells and fluids. They are obtained in abundance, 
even in excess, in the foods that are ordinarily eaten. In health, 
sodium chlorid is the only salt that need be added to foods. 

Sodium chlorid is found in all the tissues and fluids of the 
body. It is most abundant in the latter. It performs various 
functions. It gives relish to the food that contains it and im- 
proves appetite. From it the hydrochloric acid formed by the 
glands of the stomach, and so essential to digestion, is produced. 
It promotes the diffusion of fluids through membranes. It 
keeps globulins in solution in blood and lymph. It stimulates 
protein metabolism and increases the excretion of urea. Partly 
by increasing metabolism and the production of waste, and 
partly of itself, it stimulates the kidneys to increased activity. 
It is of value as a mild laxative. When taken the first thing in 
the morning with water, it will often promote free catharsis in 
those who are constipated. It is an important element in many 
laxative mineral waters. An adult in health will eat and 
eliminate 200 grains of sodium chlorid daily. The kidneys 
are the organs through which it is chiefly excreted. It is used 
extensively as a food preservative. Beef, pork, and fish are 
commonly "salted" in order to preserve them. 

Sodium carbonate and bicarbonate are found in the blood. 
They are present in the foods consumed, and are also formed 
in the alimentary tract by the decomposition of salts of the 
vegetable acids. Their presence in the blood is important 
because they help the plasma to carry carbonic acid from the 
tissues to the lungs for elimination. 



SALTS. 37 

Sodium and potassium sulphate occur in small quantities in the 
body. In part they are eaten as such, and in part are formed 
in the body by the oxidation of organic substances containing 
sulphur. 

Sodium and potassium phosphates also are important mineral 
constituents of the body, and are distributed widely therein. 
The alkaline phosphates give to the blood and lymph their 
alkaline reaction, and the acid sodium phosphate gives the urine 
its usual acid reaction. 

Potassium chlorid is widely distributed in the body, but it 
occurs in comparatively small proportion. It is most abundant 
in the muscle-cells and the red blood-cells. In general it may 
be said of potassium that it is most abundant in the cells of 
tissues, and of sodium that it is most abundant in the fluids. 

Calcium phosphate and calcium carbonate are associated in 
the tissues. The former is much the more abundant, forming 
more than half of bone. It is essential to all cell growth, and is 
present in all tissues. Magnesium phosphate occurs with the 
lime-salts, but occurs in much smaller quantity. 

Sulphur and phosphorus are introduced into the system with the 
albuminates. They occur in both animal and vegetable foods. 

Iron is essential to the maintenance of health. It is an im- 
portant ingredient of hemoglobin, and occurs in appreciable 
amounts in muscle-fibers, and in minute amounts in various 
other tissues. Only a small quantity of iron is needed to main- 
tain its balance in the system. In anemic states it is deficient 
in the blood; sometimes, however, this deficiency is due to a 
destruction of hemoglobin or of red corpuscles which cannot be 
prevented by administering iron. 

Iron is eliminated by the mucous membrane of the intestines 
but only in small amounts. Most of what appears in the feces 
when food which is rich in iron is eaten passes through the 
intestines not having been absorbed at all. 

There has been much discussion as to whether inorganic salts 
of iron are absorbed and if so whether they can make hemo- 
globin and other compounds in tissues containing iron. It has 
been proven that it can be absorbed and stored in tissues, but 
that it cannot contribute to the production of iron compounds 
in cells. What is needed for their production must be derived 



38 THE ELEMENTS OF FOOD. 

from the organic iron of foods. However, as has been known for 
very many generations inorganic iron can stimulate blood 
formation when anemia exists, that is, it can stimulate the 
appropriation of organic iron by cells needing it. 

The human body contains relatively the largest amount of 
iron at birth. As the food of infants in the first months contains 
very small quantities, this stored iron is drawn upon for the 
growth of blood during the period of rapid body development. 

For the maintenance of iron equilibrium in an average man 
ten to twelve milligrams of food-iron are required daily. It is 
probably safest to fix the standard for a diet at fifteen milligrams 
which is close to what is obtained from an ordinary diet. 
Average American dietaries afford twelve to nineteen milligrams. 
The iron in meat is chiefly in the blood which it contains. The 
following table shows the percentage in some common foods : 

Whole wheat 0052 

Spinach 0038 

Meat 00375 

Raisins 0036 

Eggs 003 

Prunes 0029 

Oatmeal 002 7 

Wheat flour 0015 

Potatoes 0012 

Corn meal 001 

Cabbage 0009 

Corn 0008 

Rice 0007 

Apples 0003 

Milk 00024 

An excess of salts will sometimes irritate the organs of diges- 
tion. An excess of lime and phosphates often gives rise to the 
formation of calculi in the urinary channels. Their absence is 
a cause or concomitant of rachitis. It is probable, however, 
that in this malady other salts also are deficient. The absence 
of the salts of vegetable acids is said to be an important element 
in the causation of scurvy. 

Most mineral salts undergo no change of form in the system. 
They are found in the tissues in the form in which they are 
eaten, and are eliminated in the same condition. Some notable 



QUANTITY OF FOODS. 39 

exceptions to this rule occur; these have already been referred 
to. Iron, for example, is greatly modified before it is combined 
with protein in the blood-corpuscles and muscle-cells. 

Mineral salts are chiefly eliminated by the kidneys and 
intestines. They are also eliminated to a small extent by the 
skin. They are contained in various secretions as products 
having functional utility or as excretions. 

Sodium chlorid when eliminated in large quantities causes 
renal casts to form and albuminuria. In much smaller amounts 
it is an irritant to kidneys already inflamed. Moreover, it has 
been found to often accumulate in the tissues of those who have 
disease of the heart or kidneys and then to lead to the produc- 
tion of dropsy. In these cases it must be almost excluded from 
the diet in order promptly to effect the absorption and elimina- 
tion of the dropsical fluid. 

As a rule, little attention is given to supplying salts to meet 
the needs of the body when more is required than is found in the 
meats and vegetables that are eaten. This need should be 
remembered, however, when but small quantities of food, or 
foods greatly diluted with water, are taken. Infants who do 
not digest cow's milk well are often given milk so much diluted 
with water that it is deficient in both fats and salts. Such 
children are especially likely to develop rachitis. 



CHAPTER V 
QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH 

Alimentary Equilibrium. Proteins and Calories. Dietary Stand- 
ards. Army and Navy Dietaries. Prison Dietaries. Diet of 
Savages. Investigations of Actual Dietaries in the United States. 

Equilibrium 

In order to determine the quantity of food that is needed to 
supply the waste that man's tissues constantly undergo and to 
supply fuel for the generation of muscular force and bodily heat 
it is necessary to study carefully the income and the outgo of the 
body. If the absorbed matter equals in weight the excreted 
matter, the body will neither gain nor lose: it will be in equi- 
librium or balance. This condition cannot long be maintained 
accurately. We habitually eat more than is needed to supply 
waste. Children must eat much more proportionately than 
adults, for they must provide for growth as well as for wear and 
tear. This habit of eating very generously is carried into adult 
life and excites many of the digestive disturbances that arise 
at that time. It also helps to produce the obesity that is so 
common in middle age. In adult life only so much food is 
needed as is required to supply energy and to repair waste. In 
old age less is needed, for less force is exerted and there is 
a gradual waste of tissue and consequent loss of flesh. 

Nitrogen equilibrium exists when the amount of nitrogen in the 
food eaten equals the amount of nitrogen in the excreta. 
This condition can be brought about and even maintained for ' 
some time by due care. It is attained, however, only as an 
experiment. By such studies we have learned that the average 
man excretes approximately twenty grams of nitrogen daily. 
The amount of nitrogen destroyed by life's processes is greater 
when the diet is chiefly nitrogenous than when it is mixed and 
contains a generous proportion of fat and carbohydrate. 
Therefore, these last are often spoken of as nitrogen savers. 
Ordinarily they furnish the fuel needed to generate muscular 

40 



THE CALORIE. 41 

power and heat, but if they are insufficiently represented in a 
diet, the nitrogenous tissues and food must supply this fuel. 

Carbon equilibrium also can be established, and the experiment 
teaches that approximately 320 grams of carbon are used daily 
by the average adult. 

Catabolism 

The catabolism or protein is nearly independent of muscular 
work, for it repairs cellular waste almost exclusively. It has 
been found, however, that nitrogen equilibrium can be main- 
tained by a supply of nitrogenous food varying between com- 
paratively wide limits. This means that nitrogenous food in 
greater quantities than are strictly needed to maintain nitrogen 
equilibrium will cause a waste of tissues as well as repair. In 
other words, all changes are stimulated by proteins. Moreover, 
when a change is made in the amount of protein eaten it requires 
a few days to bring about protein balance under the new con- 
ditions. Under normal conditions muscular work depends 
mainly, if not exclusively, on the oxidation of nonnitrogenous 
material. 

Potential Energy 

Food eaten represents potential chemical energy, the source 
of bodily energy. To determine the amount of potential energy 
in food eaten it is necessary to know how much food is consumed 
and the potential energy of food-stuffs. The calorie is the unit 
that has been fixed upon to express the energy stored in food. 
A calorie is the amount of heat required to raise one gram of 
water i°C. The most convenient way in which to estimate the 
value of food-stufls is to determine how many calories a given 
weight will furnish. It has been established that one gram of 
dry protein will furnish 4.1 calories, the same quantity of carbo- 
hydrate 4.1 calories, and the same quantity of fat 9.3 calories. 
With these facts known, it is easy to determine the calories 
that any given food-stuff will furnish, provided the percentages 
of protein, fat, and carbohydrate that it contains are known. 
These percentages must be multiplied by the figures just given 
and their results added in order to ascertain the number of 
calories in 100 grams of the food. 

As has already been shown, a certain amount of protein is 



42 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 

necessary to sustain life. It is not sufficient, therefore, to say- 
that a food to be able to maintain life and strength can furnish 
a given number of calories. Any number of calories can be 
obtained from fat, but fat will not maintain life and promote 
growth of cells. Food must be estimated in terms of protein 
required and calories required. A large proportion of the latter 
can be obtained from variable amounts of fats and carbo- 
hydrates. The number of calories required by an individual 
man will necessarily depend upon his weight and the amount of 
energy which he expends in work or muscular exercise. In 
establishing a standard, the weight fixed upon by various 
investigations has been approximately 150 pounds. The 
number of calories required by a man of this size when leading 
a sedentary life has been determined by four methods : 

1. By observing the average amount of food consumed by 
many men in different countries and under varying conditions. 

2 By observing the amount of oxygen consumed. 

3. By determining the balance of intake and output. 

4. By direct measurement of heat given off by the body. 
All of these methods have given approximately the same 

results. A man at rest requires 2000 calories and one leading a 
sedentary life needs 2300 calories daily. 

The amount of protein required cannot be so accurately 
determined. This has been attempted generally by observing 
the amount used in various places and by different people. 
Voit in Germany fixed upon 118 grams of protein as the stand- 
ard. Playfair in England fixed upon 119. Gautier of France 
fixed upon 107 and Atwater in this country fixed upon 100 grams 
for a man of sedentary habit, 125 for one at moderate work, 
150 for one at hard work and 90 for one completely at rest. 

Chittenden objects to the deduction of a standard from these 
facts; for such a standard, he says, is based upon evidences of 
self indulgence not upon the needs of an individual or the most 
profitable use of food. To determine the amount of protein 
needed he experimented on many individuals, gradually reduc- 
ing the amount of protein in their food to as low a point as was 
compatible with good health and mental and physical strength 
but permitting the calories required for the production of 
energy. In this way he found that approximately 50 grams 



RATIONS. 43 

were needed. This is the minimum which insures health and 
strength. Therefore Chittenden fixes as a standard 60 grams. 
He believes that much larger amounts overtax the organs of 
elimination and lead to disease. It must be remembered, how- 
ever, that all the organs of the human body are capable of many 
times the amount of work required of them to maintain life and 
health. Nevertheless it is to-day generally admitted that more 
protein is ordinarily consumed than is needed and often more 
than is good for one. Most recent writers have, therefore, been 
inclined to compromise between the standard fixed upon by ob- 
serving habits of eating and that fixed upon by Chittenden by 
experiment and have named 70 or 75 grams of protein as prob- 
ably the safest standard. 

It is interesting to compare these standards of 75 grams of 
protein and 2300 calories with the dietaries in the tables on 
pages 62 to 66. 

Army and Navy Ration 

The United States Army ration is as follows : 

Ounces 

Fresh beef 20 

or mutton at same price 20 

or pork 12 

or bacon 12 

or salt pork 22 

or dried fish 14 

or pickled fish 18 

or fresh fish 18 

Flour 18 

or soft bread 18 

or hard bread 16 

or corn meal 20 

Baking powder when troops are in the field. 

Beans 2 2/5 

or peas .' 2 2/5 

or rice 1 3/5 

or hominy 1 3/5 

Potatoes 16 

or potatoes 124/5 an d onions 31/5 16 

or potatoes 11 1/5 and canned tomatoes 

4 4/5 16 

or other fresh vegetables when they can 
be obtained near the post 16 



44 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 

Coffee 13/5 

or roasted 1 7/25 

or tea 8/25 

Sugar 2 2/5 

or molasses 16/25 

or can syrup 16/25 

Vinegar 8/25 

Salt 16/25 

Pepper 1/25 



When traveling a much simpler ration is temporarily fur- 
nished United States soldiers consisting of soft or hard bread, 
canned beef, baked beans, coffee, sugar and canned tomatoes. 

An emergency ration is also provided consisting of bacon, 
hard bread, pea meal, coffee or tea, saccharin, salt, pepper and 
tobacco. 

Desiccated fruits have been found almost a necessity, and 
whenever practicable are added to the ration, to obviate consti- 
pation and scurvy. When in garrison, a much more generous 
diet is had, for the regular ration is supplemented by food 
purchased by the soldiers. Woodruff carefully estimated all 
that was eaten during ten days by the men in one of our 
western garrisons, and found that in addition to the regular 
rations, such articles as oatmeal, apples, canned and dried, 
tapioca, butter, lard, canned corn, canned tomatoes, macaroni, 
milk, cheese, prunes, cabbage, apricots, barley, raisins, and 
chocolate were eaten. 

The United States Government is the only one which furnishes 
its soldiers a complete ration. Others provide soldiers with 
part of their food but expect them to purchase the rest out of 
their pay or an especial money allowance. 

For instance, English soldiers, when stationed in England, 
receive one pound of bread, three-quarters of a pound of meat, 
and about five pence to purchase vegetables, milk, sugar, and 
other articles. When in the field, a complete ration is furnished 
them that varies somewhat with the climate in which they 
serve and with the work they have to perform. 

In the United States Navy a larger variety of food is con- 
stantly used. The following is the legal ration for each person 
daily. 



RATIONS. 45 

One pound and a quarter salt or smoked meat, with three 
ounces of dried or six ounces of canned fruit, and three gills of 
beans or peas, or twelve ounces of flour; or one pound of pre- 
served meat with the same amounts of dried or canned fruit, 
and twelve ounces of rice or eight of canned vegetables or four 
of desiccated vegetables; together with one pound of biscuit, 
two ounces of butter, four ounces of sugar, two of coffee or 
cocoa or one-half of tea and one of condensed milk or evaporated 
cream ; and an allowance weekly of one-half pound of macaroni ; 
four ounces of cheese, four ounces of tomatoes, one-half pint of 
vinegar, one-half pint of pickles, one-half pint of molasses, 
four ounces of salt, one-fourth ounce pepper and one-half ounce 
dried mustard. Five pounds of lard or a suitable substitute for 
every hundred pounds of flour and yeast to make bread. 

The following substitute for the above ration may be made 
when deemed necessary by the officers in command: For the 
salt or smoked meat or preserved meat one and three-quarters 
pounds of fresh meat; instead of the articles usually issued 
with salt or preserved meat, fresh vegetables of equal value; 
for biscuits one and one-fourth pounds of soft bread or eighteen 
ounces of flour; for three gills of beans or peas twelve ounces of 
flour or rice or eight ounces of canned vegetables or for twelve 
ounces of flour or rice or eight ounces of canned vegetables, 
three gills of beans or peas. 

An extra allowance is also made when men are worked over- 
time or more than usual. 

Prison menus are simple, but supply enough in quantity and 
variety of food to maintain good health. Calculated in terms 
of protein and calories they correspond well with the standards 
of At water, Playfair, and Voit. Usually, breakfast consists of a 
vegetable soup or cereal with bread and butter or milk; dinner 
of meat or baked beans, vegetables, and bread or fruit; supper 
of bread and butter or cereal and milk. They should take into 
consideration the kind and quantity of labor performed by the 
prisoners and the opportunities or necessities for exercise or 
work in the open air. Unfortunately, individualization is 
impracticable, however necessary it may seem from a medical 
viewpoint. 



AMERICAN AND EUROPEAN 
(Quantities per man 



Dietaries. Tl Gr i ams 

Proteins. 


Gms. 
Fats. 


AMERICAN (MASSACHUSETTS AND CONNECTICUT). 


20 


40 


60 


80 


100 


120 


140 


160 


180 


200 


























Familv of carpenter in Middletown. Conn. 


114 




















127 


Family of glass-blowers in East Cambridge, Mass. 


105 




















132 


Boarding house, Lowell, Mass.; boarders, operatives in 
cotton mills 
























132 




















200 


Boarding bouse, Middletown, Conn.; / 
well-paid machinists, etc., at mod- \ Food purchased 
























127 




















186 


erate work v 
























Blacksmiths, Lowell, at. bard work _ 


105 




















155 


Brickmakers, Massachusetts; 237 persons at very severe 
work ,,. 
























182 




















368 


Mechanics, etc., in Massachusetts and Connecticut; 
average of 4 dietaries of mechanics at severe work 
























218 




















295 


Average of 20 dietaries of wage-workers in Massachu- 
setts and Connecticut _ 
























155 




















227 


Average of 5 dietaries of professional . Food purchased 


136 




















164 


men and college students in Mid- •[ 

die-town, Conn * Food eaten 
























123 




















155 


EUROPEAN (ENGLISH, GERMAN, DANISH, AND SWEDISH). 
























"Well-fed tailors, England, Playfair 


132 




















41 


Hard-worked weavers, England, Playf air 


155 




















41 


Blacksmiths at active labor, England, Playfair 


177 




















73 


Mechanic, Munich, 60 years old, in comfortable circum- 
stances, light work, Forster . , „ „ 
























118 




















68 


"Well-paid mechanics, Munich, Voit. ,., _„ 


155 




















55 


Carpenters, coopers, locksmiths, Bavaria; average of 11 
dietaries, Voit. . 
























123 




















36 


Miners at severe work, Prussia, Steinheil 


136 




















114 


Brickmakers (Italians), Munich, diet mainly maize meal 
























168 




















118 




114 




















41 


German army ordina.ry ration , war footing- 


136 




















59 


German army extraordinary ration, in war. 


191 




















45 


University professor, Munich; very little exercise, Ranke. 


100 




















100 


Lawyer, Munich, Forster 


82 




















127 


Physician, Munich, Forster . 


127 




















91 


Physician, Copenhagen, Jurgensen _ 


136 




















141 


Average of 7 dietaries of professional men and students, . 
German, Denmark, and Sweden 
























114 




















100 


DIETARY STANDARDS. 
























Adults in full health, Playfair. _ _ __ 


118 


















50 


Active laborers, Playfair 


155 




















73 


Man at moderate work, Moleschott 


132 






| 












41 


Man at moderate work, Voit 


118 






1 












55 




145 






1 












100 


Man with little physicial exercise, Atwater 


-2L 






| 












91 


Man with light muscular work, Atwater _ 


100 




















100 


Man with moderate muscular work, Atwafer 


127 




















127 


Man with active muscular work, Atwater 


150 




















150 




177 






u 












250 



46 



DIETARIES AND DIETARY STANDARD& 
per da j.) (Numbers from Atwater.) 



lit? 

fc> OS'S 


Nutri- 
Calories. tive 

ratio 




450 


900 


1350 


1800 


2250 


2700 


3150 


3600 


4050 


4500 


4950 


5400 


5850 


S300 


5750 


7200 


7650 


3100 


8550 


9000 
















































(345 


3055 








































5.5 


I 482 


3590 








































8.2 














































550 


4650 








































7.6 














































427 


4010 








































6.8 












































1382 


6905 








































7.4 














































1154 


8850 








































11 














































750 


6705 








































6.6 














































627 


5275 








































7.5 


509 


4140 








































6.6 














































491 


3925 








































6.6 














































527 


3055 








































4.7 


623 


3570 








































4.8 


668 


4115 








































4.7 














































345 


2525 








































4.3 


482 


3085 








































4 














































J 582 


3150 








































5.3 


J 636 


4195 








































6.7 














































8 677 


4540 








































5.6 


I 482 


2800 








































5 


491 


3095 








































4.6 


677 


3985 








































4.1 


241 


2325 








































4.7 


223 


2400 








































6.3 


364 


2830 








































4.4 


241 


2835 








































4.1 














































286 


2G70 








































4.7 














































528 


3140 








































5.5 


568 


J630 








































4.7 


550 


3160 








































4.9 


500 


3055 








































5.3 


450 


3 J70 








































4.7 


300 


2450 






































5.5 


350 


2800 




















| 


r ■ - 
















5.7 


500 


3520 








































5.8 


500 


4060 








































5.6 


650 


5700 














1 






















6.9 



47 



48 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 

The Diet of Savages 

It is probable that, in prehistoric times, the food of man con- 
sisted of fruits, nuts, raw meats, and fish. Such is the diet of 
some primitive tribes to-day. Cooking in some form is, how- 
ever, used by most known tribes. 

The most northern Eskimos live almost exclusively upon 
meat rich in fat and oil which constitutes an important element 
of their diet and helps to balance it. Once in a while they ob- 
tain lichens from the stomach of the reindeer and the flower 
of the arctic poppy and the so-called scurvy grass are equally 
rare articles of food with them. They eat at irregular times and 
when it is possible. 

Indians and uncivilized people in the temperate and tropic 
zones have a more varied diet. Fruits, nuts, some wild vege- 
tables, fish, wild fowl, and other game supply their wants. 
In the tropics, where fruit is abundant at all seasons, it con- 
stitutes a large and often the main part of their food. 

The diet of savages is governed by what is supplied by the 
country in which they live. The same statement, with a slight 
modification, can be made of civilized races, for they live 
chiefly upon what their country can be made to produce. 
Recently, however, since cold storage transportation has been 
made cheap and efficient, there has been effected an interchange 
of fresh commodities between the peoples of different lands and 
climates, thus no longer leaving them wholly dependent upon 
the soil on which they live. 

Relation of Diet to Seasons 

During hot seasons most persons prefer food that contains an 
abundance of water; therefore cereals, vegetables, and fruits, 
are eaten with but small amounts of meats. In cold weather 
hot soups, hot beverages, and fat meats are enjoyed. These 
changes most persons make when they can. The poor, who 
always live upon a diet restricted in character, do not make 
extensive seasonal changes and yet retain health and strength, 
The variations serve, therefore, to gratify appetite and taste, 
and arise for these reasons rather than because they must be 
made to preserve health. 

Relation of Diet to Climate. — The number of calories needed 



DIETARIES. 49 

for the production of energy is the same in all climates but at 
times more may be needed in very cold climates to maintain 
bodily temperature as well as energy. However, clothing usually 
preserves bodily temperature and therefore equalizes the dietetic 
requirements in all lands. Fats are better digested as a rule in 
cold countries than in the tropics. In the latter regions if fats 
are eaten in large amounts they are apt to provoke indigestion 
and ultimately diarrhea. Moreover, one becomes more easily 
satiated by them than in cold climates. A larger variety of 
food, particularly of fruits and vegetables, are craved in the 
tropics. The protein of beans and peas can be easily substituted 
for most of the meat eaten in temperate climates and this is 
often done by natives of the tropics. Where cooling drinks are 
craved as in cold regions hot beverages and hot soups are. 
The food used in regions climatically so diverse as the tropics 
and poles or high altitudes depend in part also on the ability 
of different kinds to keep. Many vegetables and fruits freeze 
and are thereby spoiled. Meats spoil with equal readiness in 
the tropics if they are not kept cool or otherwise preserved. 
These facts govern the dietaries of nations uncivilized and 
largely even of civilized peoples who have not sufficient wealth 
to provide luxuries. 

Dietaries of Inhabitants of the United States 

The numerous investigations upon nutrition made in various 
parts of the United States under the auspices of the Depart- 
ment of Agriculture, make it possible to state with much cer- 
tainty what articles of food are eaten, and in what quantities, 
by different classes. It is evident from these statistics that the 
people eat what their markets provide, except when poverty 
prevents purchasing. For instance, the family of a sewing 
woman of New York City averaged for one person a day in 
animal food, 26 grams of protein, 34 of fat, 15 of carbohydrate — 
equivalent to 485 calories; in vegetable food, 31 of protein, 7 of 
fat, 222 of carbohydrate — equivalent to 11 00 calories, or a 
total of 1585 calories and 57 grams of protein. This is less than 
a mere subsistence has been estimated to be. The articles of 
food consumed by this family were beef shank, pork chops, sar- 
dines, eggs, butter, milk, barley, wheat flour, bread, wheat, 

4 



50 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 

rye, rolls, cakes, crackers, sugar, beans, potatoes, radishes, rhu- 
barb, and tomatoes. The largest quantities of animal food 
consumed were in the form of eggs and milk; of carbohydrates, 
bread, sugar, potatoes, and canned tomatoes. How far short 
of the possibilities of the market this diet falls, is self-evident. 
It shows idiosyncrasies, however, or, more probably, the limita- 
tion that a lack of time or of ability to cook may have placed 
upon it. 

Most mechanics in the United States eat food that will afford 
them from ioo to 150 grams of protein and from 3000 to 5000 
calories. Many will average from 90 to 120 grams of protein. 
Atwater and Wood call especial attention to the fact that 
"our dietary is out of balance," and state that "the one-sided- 
ness is greater in the South than in the North." By this is 
meant that the ratio between protein and calories is greater than 
it should be. In the South a larger amount of protein of vege- 
table origin is eaten than in the North. 

The same comment might be made upon the dietaries of the 
families of professional men, as the table on page 5 1 will show. 

The following table of dietaries of student clubs in various col- 
leges of the country is interesting: 

WEIGHT OF DIFFERENT CLASSES OF FOOD PURCHASED PER 

MAN PER DAY 

Tennessee Missouri Connecticut Maine 

Beef , veal, mutton ... . 187 160 245 231 

Pork 89 113 91 98 

Poultry 28 12 6 100 

Fish 12 6 24 77 

Eggs 32 55 35 53 

Butter 39 27 60 52 

Cheese 7 7 

Milk 97 680 457 910 

Buttermilk 108 

Cereals, sugar, etc 564 524 361 835 

Vegetables 250 266 189 530 

Fruits.. 50 51 89 48 

The greatest quantities of animal food were consumed in 
Maine, Missouri, and Connecticut, and the least in Tennessee. 
Maine leads again in the use of vegetable foods, and Connecticut 
falls behind. In the schools of the two northern States a much 






DIETARIES. 



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CO 






















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5i 



52 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 

larger proportion of beef is eaten than in the two others. In 
Missouri a noticeably large amount of pork is consumed. In 
Maine poultry and fish are conspicuous features of the dietary, 
while they are comparatively little used in the colleges of the 
other States. Milk forms a large element of the diet in the 
States of Maine, Connecticut, and Missouri, and a noticeably 
small element in Tennessee. The diet of the club at the State 
College in Maine is much more generous in all respects than the 
others. The table on p. 53 will make this more evident. 

In Tennessee 38 per cent, of the food value was contained in 
animal food, and 62 per cent, in vegetable. In Missouri it was 
about equally divided between the two. In Connecticut 53 
per cent, was furnished by animal and 47 per cent, by vegetable 
foods. In Maine 40 per cent, was furnished by animals and 60 
per cent, by vegetables. 

The table opposite gives the same facts with reference to the 
diet of student clubs in colleges for women, and contrasts them 
with those of similar organizations for men, and with the diet 
of professional men and mechanics. The dietaries of these 
college clubs do not portray accurately those of the people of 
the different sections of the country from which the students are 
drawn, but represent them fairly. 

The negroes of the southern states have a particularly un- 
varied diet. In Alabama, about Tuskegee, where their diet 
has been most studied, their staple foods are fat salt pork, corn 
meal, and molasses. Cooking is most primitive; only two 
families of those investigated had stoves. 

The following extract from a letter of Mr Hoffman, 1 of the 
Tuskegee Institute, is of special interest in this connection: 

"The daily fare is prepared in very simple ways. Corn meal is 
mixed with water and baked on the flat surface of a hoe or griddle. 
The salt pork is sliced thin and fried until very brown and much of 
the grease fried out. Molasses from cane or sorghum is added to 
the fat, making what is known as 'sap,' which is eaten with the corn 
bread. Hot water sweetened with molasses is used as a beverage. 
This is the bill of fare of most of the cabins on the plantations of the 
'black belt,' three times a day during the year. It is, however, varied 
at times: thus collards and turnips are boiled with the bacon, the 

1 "Food of the Negro in Alabama," United States Department of Agriculture, Bulletin 
No. 38. 



DIETARIES. 





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53 



54 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 



latter being used with the vegetables to supply fat 'to make it rich'. 
The corn-meal bread is sometimes made into so-called 'cracklin bread/ 
and is prepared as follows: A piece of fat bacon is fried until it is brittle; 
it is then crushed and mixed with corn meal, water, soda, and salt and 
baked in an oven over the fireplace. Occasionally the negroes may have 
an opossum. To prepare this for eating it is first put into hot water 
to help in removing a part of the hair, then covered with hot ashes 
until the rest of the hair is removed; thereupon it is put in a large pot, 
surrounded with sweet potatoes, seasoned with red pepper, and baked. 
One characteristic of the cooking is that all meats are fried or other- 
wise cooked until they are crisp. Observation among these people reveals 
the fact that very many of them suffer from indigestion in some form." 

The following diagram taken from Atwater and Wood, 1 is 
interesting as it illustrates still more the variation of dietaries 
actually used, from the standards that have been computed. 

ACTUAL DAILY DIETARIES OF NEGRO FIELD LABORER AND 
FARMER COMPARED WITH A WELL-BALANCED 
STANDARD DIETARY 
Diet of Laborer 



Con- 
sisted 
of 



Furn- 
ished 



Con- 
sisted 
of 



Bacon 0.75ft). 

Flour 0.42ft). 

Corn meal . . .0 95ft) 
Molasses .. .0.421b. 

Protein '0.17ft) 

Calories 524°. 

Diet op Farmer 

Bacon 0.05ft). 

Lard o. 05ft). 

Flour 0.34ft). 

Corn meal. .0. 681b. 



- 1 







Furn- 
ished 



Protein . 
Calories . 



0.09ft) 
2095 



A WELL BALANCED DIET 

pum . f Protein.... o. 2 8tb. 

ished 



I Calories. . . .3500 H BSShH '< 

1 Bulletin No. 38, United States Department of Agriculture. 



DIETARIES OF NEGROES AND MEXICANS. 55 

No group of people in the United States whose diet has been 
carefully studied is comparable to the negroes about Tuskegee, 
except the Mexicans of New Mexico. 1 

"Mexicans of the poorer class raise the greater part of their food, 
which is almost entirely of vegetable origin. Flour and corn are 
used, the relative amounts depending upon the amount of money 
available. If it is necessary to reduce the cost of living to the minimum, 
as is often the case, more corn and less flour is used. 

"Probably the next article in amount, and a very important one, 
is the native bean or 'frijole' (Phaseolus sp.), which, together with 
peas and lentils, is used to supply the protein necessary in the absence 
of meats and other nitrogenous foods of animal origin. 

"Another universal article in the Mexican diet is red pepper, or 
'chili,' which, while it constitutes comparatively a rather small pro- 
portion by weight of the total food, is still consumed in enormous 
quantities as compared with the use of such material by the people 
of the eastern states. Chili is probably used more for its stimulating 
effect on the digestive organs than for the actual amount of nutrients 
which it furnishes. 

"In point of cost, probably the most important article used by the 
Mexicans not home produced is coffee. Lard is another very important 
article which is usually purchased, and which is used in considerable 
quantities. As the vegetable foods used contain very little fat, it is 
necessary to increase the amount of this substance by addition from out- 
side sources, usually either lard compound or beef tallow, which are 
the cheapest forms of fat in this region. 

"In the houses of the poorer class the cooking is done in an open 
fireplace, usually located in one corner of the room. 

"The 'tortillas,' or cakes made of flour or ground corn, are one 
of the most generally and extensively used foods. When the tor- 
tillas are made from corn, the kernels are first boiled with lime, which 
softens them. The skin is then usually, though not always, removed, 
and the grain is ground in a crude stone-grinding apparatus or 'metate,' 
consisting of a concave slab of stone and a smaller convex piece, which 
is held in the hands and which serves as a pestle. The grinding is not 
rotary, however, as in an ordinary mortar, but up and down, toward and 
from the body. The corn used is usually a small blue kind, rather soft, 
which seems to contain somewhat more than the average amount of 
fat. After the corn has been ground into a mush on the metate it is 
patted out in the hands into the tortillas. Corn tortillas are never 
rolled, as is the case with those made from flour. If flour is used, 
it is mixed into a dough with water and the cake rolled out from it. 
The flour used is not ground in the metate, but in the ordinary flouring 
mills. It is usually of poor quality, coarse, and dark colored. After 

^'Dietary Studies in New Mexico," by Arthur Goss, United States Department of 
Agriculture, Bulletin No. 40. 



56 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 

being worked into the proper form, the tortilla is baked on a flat piece 
of iron, supported directly over the fire in the open fireplace, the iron 
being first greased with lard. As soon as it is done on one side the 
tortilla is turned by pressing the moistened fingers against the "upper 
side of it, thus causing it to adhere to the fingers, whereupon it is 
deftly turned and the opposite side is browned. 

"The frijoles, or beans, are cooked in small, home-made earthen- 
ware pots, and are almost invariably combined with a very liberal 
proportion of chili and also considerable lard. 

DAILY DIETARY OF NEGRO FARMER AND POOR MEXICAN 



Negro farmer, 

animal, . 

vegetable, 
Same, 

animal, . 

vegetable, 
Same, 

animal, . 

vegetable, 
Poor Mexican, 

animal, 

vegetable, 
Same, 

animal, . 

vegetable, 
Same, 

animal, . 

vegetable, 
Same, 

animal, . 

vegetable, 



Protein. 



Grams. 

52 
40 

2 

42 

26 

33 
107 

93 

4 
82 

29 
72 



Fat. 



Grams. 



Carbo- 
hydrate. 



Grams. 



119 

5 


65 
360 


1585 
3270 


41 
16 


372 


395 
1845 


74 


26 
403 


900 
1890 


56 
19 


713 


520 
354o 


61 
19 


644 


565 
3200 


49 
23 


571 


470 
2890 


60 




680 


7 


572 


2705 



Calories. 



"The chili is cooked alone, and also with various other articles of 
food. It is prepared by first removing the stems and seeds of the 
pods, which constitute somewhat more than half of the total weight, 
after which it is sometimes ground in the metate, but is usually soaked 
in water and the inner or edible portion separated from the outer 
skin by squeezing in the hands. Owing to the extremely strong irri- 
tating effect on the hands, this operation cannot be performed by an 
amateur. The Mexican women, however, become so accustomed to it 
that it seems to have no effect on them. 

"Among the poor families the meals are served on the floor in the 
middle of the room, the family sitting on the ground around the food 
and eating without knives, forks or plates." 



CHITTENDEN S MENU. 



57 



The small amount of animal food used by some of the negro 
families studied, and its entire absence, except as it was rep- 
resented by lard, in the diet of some of the Mexicans is shown 
in the preceding table on page 55. 

The analyses show a sufficient source of heat units or of fuel, 
but great deficiency of protein. Most of the latter is derived 
from vegetables, and in several instances is altogether so. 

As the experiments of Chittenden which lead him to urge 
a great reduction in the amounts of protein eaten, have at- 
tracted attention both of dieticians and of the public the follow- 
ing dietary recommended by him and devised to put in practice 
his standards will be instructive and interesting: 



Articles 



Breakfast : 

One shredded wheat biscuit 

One teacup of cream 

One German water roll 

Two one-inch cubes butter 

Three-fourths cup coffee 

One lump sugar 

One-fourth teacup cream 

Lunch : 

One teacup home-made chicken soup. 144 

One Parker-house roll 38 

Two one-inch cubes of butter 38 

One slice lean bacon 10 

One small baked potato 60 

One rice croquette 90 

Two ounces maple syrup 60 

One cup of tea with one slice lemon . . ... 

One lump of sugar 10 

One teacup cream of corn soup 130 

One Parker-house roll 38 

One inch cube of butter 19 

One small lamb chop 30 

One teacup of mashed potato 167 

Apple, celery, lettuce salad with 

mayonnaise dressing 50 



Weight 
Grams 


Fuel-value 
Calories 


Protein 
Grams 


30 


106 


3-i5 


120 


206 


3.12 


57 


165 


5-C7 


38 


284 


0.38 


100 




0. 26 


10 


38 




3° 


51 


0.78 



60 


5-25 


no 


3-38 


284 


0.38 


65 


2.14 


55 


i-53 


150 


3-42 


166 




38 


.... 


72 


325 


1 10 


3.38 


142 


0.19 


92 


8.51 


175 


3-34 



75 



0.62 



58 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 



Articles 
Dinner : 

One Boston cracker 

One-half teacup of bread-pudding . . 

One-half inch American cheese 

One lump of sugar 

One demi tasse coffee 



Weight 
Grams 



12 

85 
12 
IO 



Fuel-value 
Calories 



47 
150 

38 



Protein 
Grams 



i-3 2 

5.25 
3-35 



From the food analyses that are given in the next chapter it 
will be easy to compute the number of calories in any diet of 
which the quantity of each constituent is known. If one so 
wishes, he may construct dietaries of standard composition 
from various foods with the aid of these analyses. 

The tables on the succeeding pages will give graphically an 
idea of the variations in eating which the habits and circum- 
stances of different individuals and groups of individuals in this 
country have fixed. 

DIETETIC FADS 

Fruitarians eat exclusively fruit and nuts or sometimes a 
little of vegetables and cereals in addition to them. Careful 
studies of persons living upon such food has not often been 
made, therefore the work of M. E. Jaffa 1 is of especial interest. 
The following summary of the elements of nutrition which each 
person, described by Jaffa, ate is instructive : 





Age 
Years 


Weight 
Pounds 


Protein 
Grams 


Fat 
Grams 


Carbo- 
hydrate 
Grams 


Crude 
Fiber 
Grams 


Calor- 
ies 


Woman 

Woman 

Girl 


33 

30 

13 

9 

6 

7 

63 

64 

10 

8 

34 

22 

25 


90 

104 

75-5 

43 

30.5 

34 
124 
136 

58 

37 

93. S 
170 
152 


33 
25 
26 

27 

24 

40 

40.3 

53- 5 

48.4 

32.3 

42.5 

85 

68 


59 

57 

52 

56 

58 

72 

53-7 

76.9 

67.7 

81.7 

81. 1 

158.7 

103 


IIO 

72 
in 
102 

97 
126 
286.3 
301.8 
246.7 
155 
156.8 
366.3 
55o.i 


40 
27 
46 
50 
37 

8 
24.6 
10 

13-4 
10.7 

9-8 

64.7 


1.300 
1,040 


Boy 

Girl 


1,25s 


Girl 


1.385 






Woman 

Boy... 


2,043 


Girl 




Woman 


1.432 


Man 









1 Bulletin No. 107 and Bulletin No. 132, U. S. Dept. Agriculture. 



DIETETIC FADS. 59 

The first six of these people lived on apples, dates, figs, 
peaches, apricots, bananas, grapes, oranges, pears, plums, 
raisins, olives, almonds, pignolia, pine nuts, brazil nuts, 
walnuts, sometimes tomatoes, celery and honey. 

They were all vigorous and healthy. The youngest never 
had had any other diet after infancy. She was undersized but 
this may have been from inheritance. During the time that 
she was studied (a period of ten days) she gained a pound and 
her brother made a similar gain in a period of twenty-two days 
while he was under observation. It was found that the coeffi- 
cient of digestibility (that is completeness of digestion and 
absorption of food) was quite comparable to that of a person on 
a mixed diet; even 80 per cent, of the crude fiber was digested. 
The ninth study and the fourth is of the same person a year 
later. At this time he took milk and eggs as well as fruit and 
nuts. One or two of the others ate cereals to a limited extent. 
The twelfth in this list was not accustomed to a fruitarian 
diet but tried it for the time of the experiment. All of the 
people studied were in good health. 

The small amount of protein and small number of calories 
which the diet of these fruitarians contained as compared with 
the average of most people is very striking. However they 
approach closely to what Chittenden has shown is all that is 
needed to maintain health and strength. 

Vegetarians eat not only fruit and nuts but vegetables, 
cereals, breads and usually milk, butter, cheese and eggs. 
From these foods a well balanced and generous ration can be 
prepared. In proportion as individual vegetarians more 
strictly adhere to a vegetable diet and reject eggs and milk 
products does their diet approach that of the fruitarians in 
value. It is interesting to compare the statistics 1 on page 60 
of a vegetable diet with those of a fruitarian diet and a mixed 
one previously given. 

These vegetarians average a larger number of calories but 
about the same relative amount of protein as fruitarians. The 
latter is far below what is used by the average man in a mixed 
diet but corresponds closely to what Chittenden recommends 
as an ideal standard. 

1 Bulletin No. 132, U. S. Department of Agriculture. 



60 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 





Age 
Years 


Weight 
Pounds 


Protein 
Grams 


Fat 
Grams 


Carbo- 
hydrate 
Grams 


Calories 


Woman 

Girl 


34 

8 
42 


93-5 

37 

83 


43 
32 
34 
49 
54 
63 
54 
74 


81 
82 
36 
51 
77 
66 
22 
28 


167 
165 
227 
324 
312 
593 
573 
700 


1,430 
1,403 
1,399 
1,998 
2,044 
3,302 
2,775 
3,431 


Woman 




64 
48 
28 
19 


136 
153 
125 
138 






Man 



Diet, Japanese. — The diet of the Japanese has been carefully 
studied by competent men of that country. Beef, mutton, 
pork and their products are scarcely eaten and were not at all 
until very recently, but fish is eaten by all who can afford it. 
The laborers in the country, however, do not average a meal of 
fish oftener than twice a month. They are vegetarians because 
they cannot afford meat and fish. They derive the protein 
which they need from cereals, beans and vegetables. Rice, 
barley and soy-beans are the staple articles of food of all classes. 
Wheat, millet, buckwheat and vegetables are also eaten but 
in smaller quantities. Fish is the staple meat, though poultry 
and eggs are eaten in small amounts and other meats in insignifi- 
cant quantities. 

The quantity of food elements eaten by different classes 
corresponds closely with the ideal standard advocated by 
Chittenden. 

Protein Calories 

Miscellaneous classes 59 grams 2,190 

Rural laborer 59 grams 2,700 

Average of 24 studies 62 grams 2,445 

These figures do not make plain all the peculiarities of the 
diet of the Japanese for as compared with our own and that of 
Europeans it is deficient in fat. The dietary studies show that 
on the average 20 grams of fat are eaten daily by those on a 
mixed diet and about 10 grams by those on a vegetable diet, 
which is from a sixth to a thirteenth of the amount consumed 
by Americans and Europeans. Moreover, the carbohydrates in 



DIET OF JAPANESE. 6 1 

the diet of the Japanese are derived in very large part from 
cereals, on the average 87 per cent., and in the diet of Americans 
only about 55 per cent, have the same origin. 

A digest of the Japanese Investigations on the nutrition of 
man by Kintamo Oshima has been published by the United 
States Department of Agriculture in which the peculiar foods 
of this people, their composition and nutritive value, are fully 
described. 



62 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 



ILLUSTRATIVE DIETARIES 
(Numbers from At water 



Dietaries. 


Proteins. (Quantities 


NEGROES NEAR TUSKEGEE 


20 


40 


GO 


80 


100 


120 


140 


160 


















No. 137, farmer __ 


31 






















No. 132, farmer. 


26 
























No. 141, farmer 


33 
























No. 100, farmer, summer 


44 


























No. 130, farmer, winter 


35 






















No.105, farm manager 


49 


























No. 136, farmer 


49 
























No. 102, sawmill laborer, summer _ . 


59 
























No. 131, sawmill laborer, winter. _ 


58 


























No. 135, farmer. _ _ _ . 


54 
























No. 101, farmer. 


71 




























No. 140, plantation band.. 


52 
























No. 138, farmer. __ _ _ ____. 


52 
























No. 99, farmer 


92 




























No. 98, farmer 


97 






























No. 133, farmer— woman 


77 


























No. 134, farmer 


86 




























No., 139, farmer... .__. 


80 


























No. 104, cotton plantation laborer. . 


99 
















* 














No. 103, cotton plantation laborer 


93 
















Averaere of all 


62 




























POOR PEOPLE, UNITED STATES. 


















25 families in poorest part of Philadelphia: 




















66 




























Largest dietary, German __ 


202 
















Average. _ _ _ __ 


109 






























26 families in poorest part of Chicago: 


















Smallest dietary 


86 
















Largest dietary 


168 
















Average „ -, . .... . , 


119 
















PEOPLE IN MORE COMFORTABLE 
CIRCUMSTANCES, UNITED STATES. 


































Farmer, Connecticut 


79 




























Farmer, Connecticut __ — 


104 
















Average 5 dietaries, farmers in Connecticut 


92 


















105 


































90 






























Boarding house,well-paid machinists,etc.,Connecticut_ 


103 


















110 
































Average 9 dietaries of mechanics, etc.... ... 


| 105 1 

















DIETARIES. 



63 



IN ACTUAL USE. 
and Wood and others.) 



in Grams. ) 


Fats. 


Carbo- 
b.ydra' 


Calories 

3S. 


180 


200 






450 


900 


1350 


1800 


2250 


2700 


3150 


3600 


4050 


4500 


4950 


5400 






































27 


304 


1625 




































83 


225 


1800 




































99 


214 


1935 






































57 


372 


2240 






































60 


389 


2295 








































138 


255 


2535 








































119 


362 


2790 










































85 


429 


2790 










































118 


390 


2932 










































85 


458 


2890 










































126 


432 


3230 












































182 


324 


3235 












































120 


467 


3245 












































124 


425 


3270 












































148 


558 


4060 
















































131 


649 


4195 
















































141 


627 


4235 
















































269 


518 


4955 




















































252 


666 


5400 




















































2S3 


649 


5400 




















































132 


436 


3270 










































































































68 


181 


1630 




































206 


608 


5235 
























































108 


435 


3235 












































































100 


213 


2195 






















( 






204 


626 


4950 




























141 


398 


3425 












































































































117 


354 


2865 










































156 


494 


3900 














































114 


483 


3420 












































136 


362 


3185 












































134 


408 


3285 












































152 


401 


3490 












































210 


412 


4090 
















































152 


420 


3570 









































64 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 



ILLUSTRATIVE DIETARIES 



Dietaries. 


Proteins. (Quantities 


PEOPLE JN MORS COMFORTABLE CIRCUMSTANCES, 

united states — continued. 


20 


40 


60 


80 


100 


120 


140 


160 


















Boarding- house, Lowell, Mass., boarders 
operatives in cotton mills 


















132 
















Average 20 dietaries of people at active exercise, 
mechanics, etc., in Massachusetts and Connecticut 


















154, 


































PROFESSIONAL MEN. 


















Average of 9 dietaries 


104 
































COLLEGE STUDENTS' BOARDING CLUBS, UNITED STATES. 


















Average of 15 dietaries 


108 




























POOR PEOPLE SCANTILY NOURISHED. EUROPEAN. 


















"Working people, Saxony, average 13 dietaries 


69 


























Mechanics, laborers, beggars, etc.,- 

Naples, Italy, averae-e 5 dietaries 


















76 


























Farm laborer, Saxony, food mainly vegetable 


80 


























Farm laborer, Prussia, food mainly vegetable 


83 




























PEOPLE IN MORE COMFORTABLE CIRCUMSTANCES. 
AT MODERATE WORK, EUROPEAN. 


















Bavaria, average 11 dietaries of carpenters, 
coopers, and locksmiths 


















122 
















Peasants near Moscow 


129 
















Average 5 dietaries of farm laborers, Bavaria 


137 
















Average G dietaries of mechanics^tc^southem Sweden 


134 
















Peasant farm laborer, Italv 


118 
















PEOPLE AT ACTIVE EXERCISE , EUROPEAN. 


















Average 5 dietaries of machinists,etc.,southern Sweden 


189 














. 


Farm laborers, Austria, diet, corn meal and beans 


159 
















Javanese in Java village World's Fair, Chicago 


6G 
















United States Army rations 


120 
















DIETARY STANDARDS. 


















European: 

"Woman at moderate work _ 


92 
















Man at moderate work__ _ _ 


118 
















Man at hard work 


145 
















American: 

"Woman with light muscular exercise, _ 


90 
















"Woman with moderate muscular work 


100 
















Man without muscular work 


100 
















Man with light, tmassftiilar work .. 


112 
















Man with moderate muscular work 


125 
















Man with hard muscular work- 


150 

















DIETARIES. 



(Continued). 



in Grams. ) 


Fats. 


Harbo- 
rydra 


Calories. 

3S. 


180 


200 






450 


900 


1350 


1800 


2250 


2700 


3150 


3600 


4050 


4500 


4950 


5400 






































































200 


594 


4650 


























































227 


626 


5275 




















































































122 


428 


3315 




























































148 


460 


3700 














































































45 


384 


2275 








































































38 


396 


2290 








































37 


504 


2740 










































17 


373 


2S45 










































































































34 


570 


3130 










































33 


589 


3250 












































55 


542 


3295 












































79 


523 


3435 




























65 


628 


3665 




























































110 


714 


4725 




















































62 


977 


5235 




























19 


254 


1490 




































161 


454 


3S50 














































































44 


400 


2425 








































56 


500 


3055 








































100 


450 


3370 














































2400 
































2700 








^H — 

| 
































2700 












































3000 
































3500 






1 
















i 








4500 

























66 QUANTITY AND KINDS OF FOOD NEEDED IN HEALTH. 






Dietaries 


Proteins 


"WASHINGTON GOVERNMENT HOSPITAL FOR THE_INSANE 


20 


40 


60 


80 


100 


120 


140 


160 




















88 






























84 






























90 






























97 






























104 
































92 




























NEW YORK HOSPITAL FOR INSANE 




















72 




























73 


























Disturbed ...... 


95 






























105 
































65 




























95 




























BOSTON 




















93 






























94 






























79 


























"W^mPTi 


118 
































94 




























Harvard students __ — 


75 
















PHILADELPHIA 




















107 
































114 






























Jews, German.Russian, Roumanian 


120 






























130 


































83 




























Irish 


135 
















CHICAGO 


















American..... -. 


117 
















German descent — . 


109 
















Trish rip.sf^ftnt 


161 


















125 
































Irish— — -_ 


131 


















189 
















Hungarian 


146 
































Bohemian 


106 
















Scotch ... 


112 
















CHINESE AND OTHER ASIATICS IN U.S. 


















Professional man and family 


115 
















Laundry Association 


135 
















Employees on Truck Farm 


144 
















Malay professional man 


73 


















66 



































DIETARIES 












6 7 




L 


Fats. 


Carbcj 
hydra 


,es Calories 




180 


200 






450 


900 


1350 


1800 


2250 


2700 


3150 


3600 


4050 


4500 


4950 


5400 






































105 


370 


2767 






































97 


350 


2599 






































73 


348 


2402 






































106 


297 


2519 






































125 


347 


2917 








































106 


368 


2783 








































































65 


348 


2259 




































65 


346 


2255 




































81 


391 


•2685 






































93 


415 


2908 








































86 


363 


2477 






































146 


376 


3186 










































































156 


349 


3156 








































131 


289 


27u0 






































94 


259 


2183 




































115 


390 


3057 








































127 


317 


2776 






































78 


312 


2243 




































































121 


374 


3001 








































116 


368 


2968 








































69 


496 


3086 








































101 


565 


3676 












































71 


474 


2861 








































129 


537 


3836 










































































151 


452 


3623 










































119 


393 


3070 








































153 


910 


5647 




















































161 


405 


3552 










































154 


441 


3660 








































_ 




198 


454 


4335 














































201 


622 


4860 
















































89 


394 


2792 








































127 


325 


2878 








































































113 


289 


2705 






































76 


566 


3580 




























95 


640 


4100 














































30 


472 


2512 


































'. 






19 


254 


1490 


















1 


1 



CHAPTER VI 

ANIMAL FOODS 

Milk and Milk Products. Composition. Variation. Adulter- 
ation. Contamination. Sterilization and Pasteurization. 
Digestion. Absorption. Predigestion. Kephyr. Kumiss. 
Matzoon. Cream. Butter. Buttermilk. Cheese. 

MILK AND MILK PRODUCTS 

Milk is universally used as an article of food by civilized and 
by many uncivilized peoples. It is one of the cheapest, most 
easily digested, and perfect foods that we use. Mother's milk 
is the natural aliment for infants. 
Composition 

Milk contains more than 85 per cent, of water and variable 
proportions of protein, fat, carbohydrate, and mineral salts. 
It contains two proteins. Fibrinogen, or casein, is the most 
important because it constitutes six-sevenths of all the protein 
in cow's milk. Lactalbumin, the second protein of milk, is 
similar to serum albumin of blood. The fat of milk consists 
chiefly of stearin, palmitin, and olein. The proportion of fat 
varies much in different kinds of milk. The carbohydrate of 
of milk is lactose, or milk-sugar. It occurs in an almost un- 
varying amount in each variety of milk. The other constit- 
uents are subject to variation. The mineral salts in milk are 
numerous, but slight in quantity. Their relative percentages in 
the ash of human milk are as follows: 

Calcium phosphate 23.87 per cent. 

Calcium silicate 1.27 per cent. 

Calcium sulphate 2.25 per cent. 

Calcium carbonate 2.85 per cent. 

Magnesium carbonate 3-77 P er cent. 

Potassium carbonate 23.47 per cent. 

Potassium sulphate & -33 P er cent. 

Potassium chlorid 12.05 per cent. 

Sodium chlorid 21.77 per cent. 

Iron oxid and aluminum ° • 3 7 per cent. 

100.00 per cent. 
68 



MILK. 



6 9 



The following table gives the comparative composition of 
milk of different kinds : 
COMPARATIVE COMPOSITION OF VARIOUS KINDS OF MILK 



Source of 
Milk 



Woman 
Cow.. . 
Dog. . . 
Ewe... 
Buffalo 

Cat 

Goat. . . 
Llama. 

Ass 

Mare. . . 



Water 






Total 




Solids 


Per cent. 


Per 




cent. 


87.4 


12 .6 


87.2 


12 


8 


75-4 


24 


6 


80.8 


19 


2 


81.4 


18 


6 


82.1 


17 


9 


85-7 


14 


3 


86.5 


13 


5 


89.6 


10 


4 


91-5 


8 


5 



Total Solids 





Protein 




Fat 










Albu- 


Total 






min 


Protein 




Per 


Per 


Per 


Per 


cent. 


cent. 


cent. 


cent. 


1.0 


1.3 


2.3 


3-8 


3 








5 


3-5 


3 


7 


6 


1 


5 


1 


11. 2 


9 


6 


5 





1 


5 


6.5 


6 


9 


5 


8 





3 


6.1 


7 


5 


3 


1 


6 





9.1 


3 


3 


3 


2 


1 


1 


4-3 


4 


8 


3 








9 


3-9 


3 


2 




7 


1 


6 


2.3 


1 


6 


1 


2 





1 


J. 3 


1 


2 



Carbo 


Min- 
eral 


(Milk- 
sugar) 


Mat- 
ters 
(Ash) 


Per cent. 


Per 




cent. 


6.2 


0.3 


4-9 





7 


3-i 





7 


4-9 





9 


4.1 





9 


4.9 





6 


4.4 





8 


5-6 





8 


6.0 





5 


5-7 


6 


3 



Fuel 
Value 

per 
Pound 



Calor- 
ies 
319 
313 
671 
503 
506 
400 
365 
312 
222 
180 



Human milk and cow's milk are not very dissimilar in the 
amount of energy that they might generate, but their food 
value, as estimated by the ratio of their protein to the calories 
that they might produce, is very different. Human milk is 
poor in protein and rich in carbohydrate. 

The average composition of human milk is: 

Water 87 to 88 

Fats 3 to 4 

Sugar 6 to 7 

Proteins 1 to 2 

Ash o . 1 to 0.2 

It is slightly alkaline, and has a specific gravity of from 1028 
to 1034. The following analyses, made by Harrington for 
Rotch, illustrate the variability of human milk: 

I II III IV V VI VII 

Fats S.16 4.88 4.84 4.37 4. 11 3.82 3.80 

Sugar 5.68 6.20 6.10 6.30 5.90 5.70 6.15 

Proteins 4.14 3-7 1 4. 17 3- 2 7 3 7 1 1 -° 8 3-53 

Ash 0.17 0.19 0.19 0.16 0.21 0.20 0.20 



70 ANIMAL FOODS. 

VIII IX X XI XII XIII XIV 

Fats 3-7^ 3.30 3.16 2.96 2.36 2.09 2.02 

Sugar 6.95 7.30 7.20 5.78 7.10 6.70 6.55 

Proteins 2.04 3.07 1.65 1.91 2.20 1.38 2.12 

Ash 0.14 0.12 0.21 0.12 0.16 0.15 0.15 

The fats and proteins may vary very much more than these 
analyses would lead one to think. The following analyses 
show how greatly a mother's milk may vary from time to time : 

Standard Case I Case II 

Fats 4.00 0.72 5.44 5.50 1.62 3.20 3.04 

Sugar 7.00 6.75 6.25 6.60 6.10 6.40 6.60 

Proteins.... 1.50 2.53 4.61 2.90 3.54 2.52 2.32 

Ash - x 5 0.22 0.20 0.14 0.17 0.18 0.12 

Case III Case IV Case V 

Fats 1.62 3.20 3.04 1.37 2.02 2.74 3.05 0.65 3.34 

Sugar 6.10 6.40 6.60 6.10 6.55 6.35 6.10 5.25 6.30 

Proteins 3-54 2 -S 2 2 -3 2 2.78 2.12 0.98 3.89 3.82 2.61 

Ash 0.17 0.18 0.12 0.15 0.15 0.14 0.16 0.18 0.16 

Case VI Case VII Case VIII 

Fats 3.44 2.09 3.98 3.19 5.71 2.67 0.34 3.24 2.79 4.84 

Sugar 5.60 6. 70 7.00 5.60 4.00 6.60 5.40 5.45 5.05 6.00 

Proteins.... 3.96 1.38 2.22 1.78 4.29 3.18 3.61 3.95 3.66 3.42 

Ash 0.20 0.15 0.19 0.16 0.19 0.17 0.18 0.16 0.20 0.17 

Cow's milk varies almost or quite as much as human milk. 
The most constant ingredients in it are milk-sugar and mineral 
matter. The following is an average analysis of cow's milk: 

Water 86 to 87 

Fats 2.5 to 4.50 

Sugar . 4 to 4 . 50 

Proteins 3 . 75 to 4 . 00 

Ash , 0.70 

It is slightly acid in reaction and has a specific gravity of 
1029 to 1033. The milk of a cow may vary in composition at 
different times. It is usually richer in cream for a time after 
her calf is born than later. Food, excitement, and illness will 
also cause it to vary. So long as the animal is upon a uniform 
diet and is healthy, her milk will not vary noticeably in com- 
position or amount. Different breeds give milk of varying 
degrees of richness: 



VARIATIONS IN MILK. 7 1 

Durham Devon Ayr- Hol- Swiss 

shire stein 

Fats 4.04 4.09 3-89 2.88 4.00 

Sugar 4.34 4.32 4.41 4-33 4-3° 

Proteins 4. 17 4.04 4.01 3-99 4.00 

Ash °-73 0.76 0.73 °-74 0.76 

Good cow's milk should contain from 3 to 5 per cent, of fat. 
Variation 

The proportions of the constituents of milk vary from the 
filling of the cow's udder after calving to the time when it 
ceases to be secreted. After the first week it is usually the 
richest and remains about the same for months, providing the 
animal's diet is uniform. Ultimately the milk becomes less 
abundant, but the percentage of solids increases. 

The flavor of milk is frequently modified by diet; certain 
plants may make it disagreeable. 

Milk is more nearly uniform when it is obtained habitually 
from a herd of cows; that procured from one animal varies 
much from time to time. 

Adulteration 

As it is purchased from dealers, milk is at times modified in 
composition or adulterated. The addition of water is the 
commonest mode of adulteration. If the water is pure, its 
addition is harmless, except as it lessens the nutritive value of 
a given quantity of the milk. Coloring-matter is added to 
make milk look richer. Milk is sometimes slightly thickened 
by the addition of starch. Preservatives, such as salicylic and 
boric acids and formaldehyd, are mixed or dissolved in it. 
They prevent its souring rapidly. Although these agents are 
used in very small percentages, and, if taken occasionally, 
would probably be harmless, they must be regarded as deleter- 
ious when administered habitually, as they may be in milk. 

Contamination 

Milk is often unwholesome because it is obtained from cows 
that are not healthy. The commonest cause of its contamina- 
tion is disease of the udders, but even disease in distant organs 



72 ANIMAL FOODS. 

makes it undesirable. Milk taken from a sick cow should not 
be used for food. Unfortunately, chronic maladies like tuber- 
culosis may exist in an animal for a considerable time without 
causing sufficient change to attract the keeper's attention. 
Tuberculosis of the udder or slight inflammation due to pyogenic 
microbes may easily be overlooked. Of 186 samples of milk, 
Dr. Eastes 1 found tubercle bacilli in n and pus organisms in 47. 
Milk is often contaminated by dirt, which comes from the cows 
when they are not properly cleansed before milking, from the 
hands or clothes of the milker, or from the dust of the stable, 
barnyard, and milk room. Besides dirt, micro-organisms of 
various kinds gain access to it in this way. Some are innocuous, 
a few produce souring, and others are specifically pathogenic. 
Of the last, the commonest are the microbes of typhoid fever 
and diphtheria; and, possibly, of scarlatina and, in certain 
countries, of cholera. The typhoid and cholera germs are 
added to the milk with water used in cleansing the vessels in 
which the milk is gathered or kept, or added as an adulterant. 
They are also sometimes carried on the feet and proboscis of 
flies which convey them from sewerage to the home or dairy. 
They both grow freely in milk when it is kept sufficiently warm. 
Local epidemics of typhoid fever have frequently been traced 
to milk thus contaminated. Scarlet fever has been said to be 
communicated by milk when cows were milked by one who 
was recovering from the malady and who had not yet com- 
pletely shed the skin of his hands. 

In a report upon milk examination made by de Schweinitz, 
of Washington, to the Department of Agriculture, attention is 
called to the fact "that in the milk supply of our large cities the 
number of bacteria per cubic centimeter has been found to vary 
from 30,000 to 85,000, and has often been found as high as the 
number of bacteria in the sewage of several towns — namely, 
between 1,000,000 and 4,000,000 per cubic centimeter." But- 
ler, a German authority upon the subject, claims that the 
maximum limit for milk that is fit for food is 50,000 germs in a 
cubic centimeter. If this rule is applied to samples obtained 
by de Schweinitz from 32 Washington dealers, the milk supply 
of only 13 was fit for use. Of the samples from these dealers, 

1 " British Medical Journal," November n, 1899. 



CLEAN MILK. 73 

one showed only about 4000 bacteria in a cubic centimeter; 
one, 2500; five others, from 10,000 to 15,000; six, from 30,000 
to 50,000; and the remainder, more than 50,000; in several 
instances, more than 100,000. De Schweinitz also examined 
135 samples of milk obtained from a dairy in which the utmost 
pains were taken to prevent contamination. In a majority 
of these samples from 200 to 5000 bacteria in a cubic centimeter 
were found. Three samples showed more than 50,000, one 
more than 15,000 and less than 20,000; two more than 10,000 
and less than 15,000; two more than 5000 and less than 10,000. 
These results show what can be accomplished by due care. 
Legal standards, both chemical and bacteriologic, have been 
established by certain health boards in the United States and 
other countries. The milk supply of communities thus safe- 
guarded has consequently been greatly improved and made more 
uniform. 

All this emphasizes the need of the utmost care in the handling 
of milk to insure its purity. Purity is the more necessary as 
milk is so largely used uncooked. 

At the Clover Farm Dairy, which offers a particularly uniform 
rich and pure milk for use in Chicago, the following precautions 
are taken : 

The herd is made up of grade Holsteins, grade Jerseys, and 
grade Durhams. These crosses are thought to give animals 
more vitality, better constitutions, and less liability to disease 
than the registered animals of the various breeds possess. It is 
also important, in the production of milk for baby and invalid 
food, to secure milk that retains its cream as well as possible. 
The cream of Jersey milk rises so rapidly that a thick buttery 
cream is produced that does not mix so readily with the milk 
after it has once risen as does that of most of the other breeds 
and their grades. This characteristic of the Jerseys adds to 
their value as butter cows, but detracts from their usefulness 
when a milk is wanted to retain its fat. Milk should be con- 
stantly agitated during the cooling process, for this prevents 
the rising of the cream until after it is cooled, and by this 
treatment cream and milk are much more readily and thor- 
oughly incorporated when preparing it for feeding. 

Each cow is tested for tuberculosis at frequents intervals, and 



74 ANIMAL FOODS. 

also to determine her value as a butter producer. A cow not in 
perfect health cannot reach a high productive standard. These 
tests insure a healthy herd from which the milk is obtained. 

The stable has cement floors and cement mangers. It is fur- 
nished with individual stalls. The stall work is of iron and 
woven wire. It has a good system of ventilation and has plenty 
of light. 

The cement floors can be easily cleaned, and every day they 
are thoroughly flushed and scrubbed, abundance of water being 
at hand. A complete system of sewerage is provided. 

One-half hour before milking, the cows are groomed. The 
milkers are required to cleanse their hands and put on white 
milking suits. One man is required to cleanse the udders of the 
cows just in advance of milking, using a sponge and warm water 
for this purpose. Each milk pail is furnished with a closely 
fitting strainer cover, into which is fastened a layer of absorbent 
cotton, so that all the milk passes through this cotton before 
entering the milk pail. The milk is poured out through a 
covered spout, and the strainer is not removed from the pail 
until the milking is finished, when it is destroyed and a new one 
is prepared for the next milking. The milk pails, strainers, 
cans, and all other utensils, also the bottles in which the milk 
is shipped to the consumer, are thoroughly cleansed and then 
sterilized by live steam in a sealed room, the temperature of 
which is held at 2 1 2 F., for thirty minutes. The first milk from 
each teat is rejected, as experience has shown that germs which 
may sour the milk invade the milk-ducts and cannot be gotten 
rid of by washing alone. 

As soon as the milk is obtained it is run through a centrifugal 
machine, such as has been in use for some years in creameries, as 
a means of rapidly and economically separating the cream from 
the milk. By its use the percentage of fat can be kept constant, 
and at the same time dirt or other solid matter that may have 
gotten into the milk in spite of the precautions previously used 
can be removed from it. Although in this operation the cream 
and milk are separated from each other, they are again mixed 
when they come from the separator, and there is left behind in 
the machine a peculiar mass of mucus, germs, etc., which it is 
very desirable to have out of the milk. Immediately after 



STERILIZATION AND PASTEURIZATION. 75 

leaving the separator the milk is cooled to a low temperature. 
The milk is then bottled, each bottle stopped with a wood-pulp 
stopper, and a metal cap and a seal put over the top in such a 
manner that the contained milk cannot be reached unless the 
seal is destroyed. On each seal is stamped the date of the 
bottling. This seal is a guarantee of genuineness to the con- 
sumer. Although this process seems complex, it is in reality 
carried out quite readily by trained workmen. 

The dairies which supply the Walker-Gordon Milk Labora- 
tories in various cities are managed in much the same way, and 
an equally uniform and pure production is the result. 

In several cities of the United States the whole or a part of the 
milk-supply has been taken under the voluntary supervision of 
medical societies cooperating with reputable dairymen. The 
societies appoint veterinarians, bacteriologists, and chemists. 
They fix and announce their requirements, and these are 
specified in contracts. Every month, at times not previously 
announced, samples of milk are procured and examined, and 
the veterinarian visits the dairy farm. If the milk examined 
comes up to the standard, a certificate is given; if not, the 
certificate is withheld until another examination shows the 
milk to be right. Inside of the metal cap on every bottle is a 
small certificate, printed and signed with the printed autograph 
of the Commission, stating that an examination was made on 
such and such a date, and that another will be made within 
the month and new certificates issued, and counseling buyers 
to watch for the change in dates. 

Sterilization and Pasteurization 

Pathogenic organisms in milk can be killed by boiling it. 
This constitutes sterilization. It is, however, then changed in 
taste and made distinctly less digestible. If milk is kept at a 
temperature of 70 C. (158 F.), for twenty or thirty minutes, 
most of the germs will be killed. Their spores will not be 
destroyed but their growth will be checked for a time. This 
process is called Pasteurization. It does not modify the 
taste of the milk, nor lessen digestibility so much as steri- 
lization does. Except in the hottest summer weather, 



76 ANIMAL FOODS. 

resort to Pasteurization is not necessary to prevent the 
souring of milk. Pathogenic organisms should be excluded by- 
scrupulous care in the collection and distribution of milk. 

Digestion 

Milk is easily digested by most persons. It is usually spoken 
of as a liquid food, but when it reaches the stomach it is con- 
verted at once into a finely divided solid. Its casein is curdled 
and precipitated in flocculent particles by rennin, the milk- 
curdling ferment of the stomach. The gastric acids coagulate 
it also. When this process goes on with unusual rapidity, 
instead of flocculent particles of casein there may be formed 
large masses of cheese-like material that will prove slow of 
digestion. This often occurs in the stomachs of both infants 
and adults whose digestion is enfeebled. Cow's milk curdles in 
larger particles than human milk, and is therefore more difficult 
of digestion. After milk is curdled in the stomach its compo- 
nents are digested as are other foods. 

It is often important to prevent the formation of large curds 
in the stomach. Adults who feel uncomfortable after drinking 
milk can frequently be taught to like it and to dispose of it readily. 
It must be given at first in small doses — one or two tablespoon- 
fuls every quarter or half hour — and gradually in larger 
quantities and at longer intervals. Patients should be instructed 
to drink milk slowly, sipping or 'chewing' it; often hot milk 
will be found better than cold milk for this purpose, and those 
who become accustomed to the flavor of heated milk usually 
prefer it. Giving it in small quantities prevents it from forming 
large cheese-like masses in the stomach ; and the same purpose is 
accomplished by slow sipping, and thorough mixing with the 
saliva. Lime-water is frequently added to milk to prevent it 
from coagulating into large chunks of casein. Usually two or 
three tablespoonfuls are added to a glass of milk. Lime-water 
partly neutralizes the acids in the stomach and prevents them 
from still further contracting or coagulating the milk curds. 
Other antacids are useful for this purpose. Sodium citrate is 
added to milk to prevent coagulation which it does by convert- 
ing the soluble lime salts into insoluble citrate. For this pur- 



ABSORPTION OF MILK. 77 

pose, add to milk, one-fifth of its bulk of a 25 per cent, solu- 
tion of sodium citrate. It is scarcely detectable by taste. 
Aerated waters, such as Vichy and Selters, when added to milk 
increase its palatability for many persons and combat its dot- 
ing, in part by diluting it and in part by making the clot 
friable. Dilution of the milk also insures dilution of the acids in 
the stomach. Barley-water and flour ball are used to prevent 
the formation of large, firm clots in the stomach. They do this 
by mingling with the particles of casein the mucilaginous 
particles of starch, which prevent the clot from shrinking into 
a tough mass. 

Boiled milk does not clot so firmly as raw milk out of the 
stomach, but in the latter it does. Boiling renders some of 
the lime-salts less soluble, but when they are introduced into 
the stomach, they are redissolved by its acid. 

It is interesting to note the time that milk remains in the 
stomach after it is taken. This is determined by drinking a 
measured quantity and by washing the residue out of the 
stomach at different times. It has been found 1 that — 

602 c.c. of raw milk disappeared from the stomach in three and one- 
half hours. 
602 c.c. of skimmed milk disappeared from the stomach in three and 

one-half hours. 
602 c.c. of sour milk (buttermilk) disappeared in three hours. 
602 c.c. of boiled milk disappeared in four hours. 

However, the correctness of these figures is disputed by all good 
observers and it is still undecided that there is a difference in the digest- 
abilility of boiled and raw milk. 

Absorption 

Milk is not completely absorbed from the intestine. In 
adults it leaves a considerable residue. In infants and children 
it is much more completely taken up. In childhood the residue 
is about 4 per cent., as compared to 10 per cent, in adults, and 
is still less in infants. If two liters of milk are the only food 
taken by an adult, the residue will be from 5 to 8 per cent.; if 
three liters are taken, from 10 to 11. 16 per cent, will remain 

1 Hutchison, "Food and the Principles of Dietetics," p. 122, London, 1911. 



78 ANIMAL FOODS. 

unabsorbed. When milk is taken with other food, a similar 
residue is left; for instance, on an exclusive milk diet 92.1 per 
cent, of protein and 86.3 per cent, of carbohydrate will be 
digested and absorbed, and upon a bread and milk diet 97.1 
per cent, of protein and 98.7 per cent, of carbohydrate will be 
digested and absorbed. 

Utility in Disease 

Milk is particularly well adapted for use in many diseases 
because it is easily digested, comparatively unirritating, and, 
when used exclusively, lessens abnormal fermentation in the 
intestines. No single food is so valuable to the sick. It 
occupies a unique position, for it is easily administered and it 
combines in itself the qualities of a beverage and of a food. It is 
a bulky food, however, because it contains so much water. 
When a patient is confined to his bed, three or four pints daily 
will maintain life and sometimes even increase his weight, but a 
person in health, engaged in active work, will need twice this 
amount. 

The milk cure, or an exclusive milk diet, has been recom- 
mended for very many diseases. It is carried out systematic- 
ally at certain health resorts, especially in Switzerland and 
Germany. Its applicability in pathologic states is discussed in 
the second part of this volume. When milk forms the only 
article of diet, it should at first be given in quantities not to 
exceed from one-third to one-half glass every second hour. 
After two or three days, two-thirds of a glass can be given at a 
time, and later a whole glass, or about eight ounces. It should 
be drunk slowly, or sipped. It should be taken with perfect 
regularity during the day, and two or three times at night. As 
many as twelve glasses (three quarts or liters) are usually 
prescribed for use in twenty-four hours. Constipation is not an 
unfavorable indication when milk only is taken as food. It 
means that the milk is well digested and well absorbed, and it 
can be counteracted by mild laxatives. Vomiting and diarrhea, 
however, indicate indigestion and malassimilation. At first, 
patients upon a milk diet lose flesh, but when they take the 
maximum quantity, they hold their own or gain. They often 



PREDIGESTED MILK. 79 

feel drowsy. The tongue is thickly covered by a white or 
yellowish-white pasty coat and a disagreeable mawkish taste is 
often complained of. 

The urine is increased in quantity. The output of uric acid is 
lessened. Indican and compounds of similar origin disappear. 

If milk was the only food a person took, its bulk would be 
uncomfortably large, providing enough was taken to furnish 
2500 or 3000 calories, for 100 grams (three and one- 
third ounces) furnishes 69.2 calories or units of energy and 
approximately 3.3 grams of protein. Therefore, as the only 
food for a person it is only adapted to those who are at rest in 
bed. For others it can be made a more perfect ration by adding 
sugar to it or by giving with it a little bread or crackers. 

The milk cure is persisted in for six or eight weeks ordinarily. 
It is not suddenly discontinued, but milk is given in gradually 
lessened amounts, and other easily digested foods are substi- 
stituted for the quantities withdrawn. 

It is sometimes necessary to modify the flavor of milk when 
it is used as an exclusive food or as the chief article of diet, as 
the taste of it is not agreeable to every one. Warm milk is 
preferred by many, and is particularly well borne by the stom- 
achs of most persons. A little salt and pepper are sometimes 
added to milk to modify its taste. 

Predigestion 

When milk is administered to those whose digestive organs 
are weak and incapable of full work, it is often partly digested 
beforehand. This is accomplished by adding to milk that has 
been slightly acidified a good preparation of pepsin. The 
mixture is kept at body-temperature by immersion in hot 
water. The proteins of the milk are soon converted into albu- 
moses. If digestion is allowed to continue, the mixture becomes 
bitter. It is customary, therefore, to remove the milk from 
the hot water before it grows bitter and to place it upon ice 
until it is used. Pancreatin is employed more often than pepsin 
for the digestion of milk, for it acts in an alkaline medium. A 
small amount of pancreatic extract and a few grains of sodium 
bicarbonate are dissolved in water and added to the milk. 



80 ANIMAL FOODS. 

The mixture is kept at body-temperature or slightly higher, 
usually by placing the containing vessel in water at from ioo° 
to no° F. for about fifteen or twenty minutes until a slightly 
bitter taste is developed. The ferment is then destroyed by 
quickly bringing the milk to a boil and afterward placing it 
upon ice; or it may be placed upon ice without the preliminary 
boiling, in which case the activity of the ferment will be 
checked, but not destroyed. In what is termed the cold pro- 
cess, the digestive powder is dissolved in water added to the 
milk, and the whole placed upon ice, or allowed to stand, 
properly covered, in a cool room and used as wanted. Fair- 
child's tubes of peptonizing powder are composed of pancreatic 
extract five grains and sodium bicarbonate fifteen grains. One 
of these tubes will digest a pint of milk. There are various 
other good preparations upon the market. To prevent curd- 
ling of the milk by the digestive powder it is necessary to dis- 
solve the latter in a sufficient quantity of water — about one- 
fourth the bulk of the milk to be prepared. This holds good 
for all methods of preparation. Milk that is predigested in these 
ways should be taken cold. Its bitter taste may be disguised 
by the addition of a little coffee or carbonized water. The taste 
of the digested milk can also be well disguised by mixing 
together equal parts of milk and of flour gruel before the pan- 
creatic powder is added. In many cases it will suffice to dis- 
solve the necessary quantity of peptonizing powder in sufficient 
cold water, stir this into warm milk, and give to the patient at 
once, before the bitter taste develops. Milk thus prepared is 
sometimes termed 'pancreatized milk,' to distinguish it from 
the peptonized milk that has been allowed to stand. It is rare 
for a patient to object to the taste. 

To make milk more digestible for certain persons, and espe- 
cially for infants, its components are modified in their propor- 
tions by diluting it with water and by adding, if need be, cream 
and milk-sugar. Such milk modification or the preparation of 
percentage milk is described as a part of infant feeding in a sub- 
sequent chapter. 

Kumiss is a milk preparation that is agreeable to many pa- 
tients, very readily digested, and more completely absorbed 
than ordinary milk. It has been made for many hundred years 



KEPHYR. 8 1 

in Eastern Europe from mare's milk. A substitute for it, made 
from cow's milk, is called kephyr. 1 All so-called kumiss in this 
country is kephyr. The presence of more fat in cow's milk than 
in mare's milk makes it less suitable for the fermentation that 
must take place to convert it into kephyr; therefore it is diluted 
or modified before it is fermented. The ferments used effect 
several changes in the milk. A part of the sugar in it is con- 
verted into lactic acid; another part into alcohol and carbonic 
acid gas, and a small amount of the casein is digested. The 
lactic acid precipitates the casein in fine particles; by constant 
agitation they are made still finer and gradually undergo partial 
digestion. The product is a milk that is sour, effervescent, and 
weakly alcoholic. The following table from Hutchison gives 

1 Kephyr, like kumiss, was first made in the Caucasus by fermenting cow's milk with 
saccharomyces mycoderma, which produces alcohol, and lactic-acid-forming organisms. 
The kephyr granules used in the Caucasus to start this fermentation contain also bacterium 
dispora caucasica. It was supposed this played a part in producing the beverage — kephyr 
— but recent investigations show that it produces little or no effect. It may help to liquefy 
the precipitated casein. 

According to C D. Spivak (" N. Y. Medical Journal," Jan. 18, 1896, p. 82): "The Tar- 
tars prepare the kephyr in the following manner: A leathern bag (burdjuck) is filled with 
fresh cow's or goat's milk, the kephyr grains are thrown in, and the bag is tightly tied up. 
In summer the bag is placed in the shade, and in winter where the sun can reach it. From 
time to time the bag is shaken. The children take the office upon themselves, and usually 
the bag is used as a ball. It is also considered a duty that every passer-by should kick the 
bag, and set it rolling. In a few hours, or, at the utmost, two days — according to the 
season — the kephyr is ready for use. The bag is emptied and refilled, using the same grains 
over and over again. 

"The method of preparation now used in civilized countries is that elaborated by Dr. 
Dmitrieff. The grains are placed in an earthern or darkened glass vessel and are covered 
with milk, the bulk being three times that of the grains. The mouth of the vessel is 
covered with gauze or hygroscopic cotton with a view to exclude the ingress of dust only, 
and not to make it air-tight. The vessel is placed in a cool place at 12 R., and as soon 
as the fermentation sets in — i.e., as soon as the grains rise to the surface of the milk — the 
vessel is to be shaken up every two or three hours, with a view to thoroughly mixing up 
the fluid and liberating the grains from the curds and the bubbles. After twenty-four 
hours the grains are separated from the fluid by means of a sieve, are placed in a clean vessel, 
and a new quantity of milk is poured on them. Unlike the Tartar method, this product is 
not used as a beverage, but as a fermenter,' or, as it is called in Russia, 'zakvaska.' The 
zakvaska is diluted with double the quantity of milk and poured into bottles, which are 
corked hermetically. The bottles must not be completely filled, as they may burst. They 
are kept at the same temperature as the zakvaska, but they do not require the exclusion of 
light. The shaking is to continue at regular intervals, but not so that it may churn the 
milk. In twenty-four hours the kephyr is ready for use, and it is called the first day's 
kephyr, or weak kephyr. It has the following characteristics: the consistence of thin, 
sour cream, a white color, a pleasant, sour-sweetish taste, slightly acrid. When the 
bottle is opened it effervesces. The walls of the bottle and the glass which have held kephyr 
are covered with fine curds. When the bottle is left under the same conditions for another 
twenty-four hours, the kephyr is called second day's or medium kephyr; in forty-eight hours, 
third day's or strong kephyr. The terms weak, medium, and strong kephyr refer to the 
quantity of alcohol and carbonic acid gas contained in it." 

6 



82 



ANIMAL FOODS. 



the relative composition of kumiss and mare's milk, of kephyr 
and cow's milk, and compares them with each other: 





Protein 
Percent- 
age 


Sugar 
Percent- 
age 


Fat 
Percent- 
age 


Salts 
Percent- 
age 


Alcohol 
Percent- 
age 


Lactic Acid 

Percbnt- 

AGB 


Kumiss 


2.2 
2.6 

3-1 
3-3 
3-8 


i.5 

5-5 
i.6 
4.8 
3-3 


2. I 
2-5 
2 .O 

3-6 

1.2 


0.9 

°.5 
o.8 
0.7 
o.6 


i.7 


0.9 


Kephyr 


2. I 


o.8 






0.3 







When kumiss or kephyr is fermented for only twelve hours, it 
is slightly sour and resembles milk in taste and appearance; 
when fermented for twenty-four hours, some of the casein will be 
dissolved, and the kumiss will be thinner and sourer. If the 
process is continued another day, it will be still thinner, sourer, 
and more thoroughly charged with carbonic acid gas. 

In Russia there are many places where the kumiss cure is 
applied. Those who need the cure are placed in sanatoriums, 
taught to drink large quantities of kumiss, and also fed gener- 
ously of other foods. The change of climate, the influence of 
the sun, and the fesh-air life have much to do with the cures 
that are effected at these resorts. At first, four or five glasses 
of kumiss are given daily. By degrees more is given, until 
from fifteen to twenty are taken in a day. It is especially 
valuable in some chronic catarrhs of the alimentary and respira- 
tory tracts, the early stage of pulmonary tuberculosis, anemia, 
scrofula, and rachitis. It is certainly nutritious and distinctly 
diuretic. If kumiss is too fresh or has not been kept clean, it 
may cause flatulence, colic, and diarrhea. It is often used as a 
substitute for milk by those who prefer its taste. 

Matzoon is a fermented milk. A lactic acid ferment obtained 
from Syria is used in its manufacture. It is sour, thicker, and 
is more of the consistency of cream than kumiss. It does not 
contain alcohol or carbonic acid gas, and is taken in smaller 
amounts at a time. It is agreeable, very readily digested, and 
also highly nutritious. 



CONDENSED MILK. 83 

Preservation 

In countries where fresh milk cannot be had, milk is con- 
densed to preserve it for use. It is evaporated in vacuo until it 
becomes thick and paste-like. Two kinds of condensed milk 
are to be had in the market: one unsweetened, the other con- 
taining cane-sugar. In the former the proportion of water is 
reduced from 88 to 60 per cent. The latter contains from 40 
to 75 per cent, of sugar. Condensed milk is often used as an 
infant's food. Some children grow fat upon it, but rarely thrive 
long. They are prone to rachitis. Their flesh is generally soft, 
and they do not resist disease well. 

Cream contains most of the fat of milk. It is obtained 
either by permitting milk to stand, when the fat will rise to 
the top and can be skimmed off, or it may be obtained more 
rapidly and perfectly by means of the centrifugal cream separa- 
tors now so generally used by dairymen. The proportion of 
fat in cream varies greatly. Ordinarily it is from 15 to 20 per 
cent, of the whole. Cream separators will produce a cream 
containing 65 per cent. fat. It is quite as essential that a 
legal standard should be fixed for cream as for milk. Cream 
contains about the same percentage of protein and sugar as 
milk. The fat in it displaces only some of the water that milk 
contains. 

Cream is agreeable to most persons, and is one of the most 
easily digested fats. Although not quite so digestible as cod- 
liver oil, it is an excellent substitute for the latter, because it 
is more willingly taken in sufficient quantities. A pint of 
cream will furnish 125 more calories (1425 calories) than four 
quarts of milk. It is a heat producer or energy producer, and 
should be supplemented by porteins to make a complete diet. 

Ice-cream, when made simply, is wholesome and agreeable. 
It may be fed to many invalids with benefit. It is cream 
flavored with vanilla, sweetened with sugar, and frozen. Ice- 
cream that contains rich flavoring extracts or much fruit is 
less easily digested. 

Skimmed milk is the residue left when cream is removed 
from milk. It is milk poor in fat. Its composition varies 
inversely as that of the cream that has been removed from it. 



84 ANIMAL FOODS. 

It is adapted for use when the fat of milk cannot be well 
digested. 

Butter is produced from cream by churning. In this process 
the albuminous envelops of the fat globules of the cream are 
broken and the fat particles are permitted to commingle and 
to form a solid mass. The fluid residue contains most of the 
sugar and protein of the cream. The flavor of butter is derived 
from the growth of organisms in it while it is ripening. In many 
creameries pure cultures of certain micro-organisms are now 
used to ripen butter and thus insure a uniform flavor to their 
product, or to adapt the flavor to the preference of certain 
markets. Butter prepared from fresh cream has not what is 
known as the butter flavor. It is comparatively insipid. Salt 
is mixed with butter to preserve it and to flavor it. When 
butter is not salted, it spoils quickly. When it spoils it becomes 
rancid, bitter, and unwholesome. These changes take place 
readily if it is kept in too warm a place. 

Two one-inch cubes of butter weigh approximately an ounce 
and furnish 284 calories and 0.38 grams of protein. 

Butter is often adulterated by coloring matters and by admix- 
tures of other fats. Margarin is prepared from ox fat, and is 
quite as digestible and wholesome as butter. When mixed 
with it, an agreeable fat results that is much cheaper than 
butter. It is known as butterin. If it is well made, it is not 
harmful. Butter that has become partly rancid may be washed 
repeatedly with hot water and again 'worked'; it will taste 
nearly as well and be as cheap as butterin, but it is not equally 
wholesome. 

Most persons eat an ounce of butter or more daily. As a 
rule, it is very easily digested. Although it is less digestible 
when cooked than when used cold. 

Butter contains from 12 to 5 per cent, of water, 82 per cent, 
of fat, and about 2 per cent, of other organic matter. Margarin 
contains 9.3 per cent, of water, 1.3 per cent, of protein, 82.7 
per cent, of fat, and 6.7 per cent, of ash (Atwater). 

Buttermilk, or the residue after butter is made from milk, 
contains albumin, salts, sugar, and water. Much of the sugar 
is converted into lactic acid and gives to buttermilk its sour 



CHEESE. 85 

taste. It is relished by many persons and particularly well 
digested by those who cannot eat fats. 

In Turkey, Bulgaria, Servia and the neighboring countries 
sour milk has been used as a beverage very generally and is 
preferred to sweet milk. The bacterium caucasicus or Bul- 
garian bacillus is the most active of the lactic acid ferments. 
It has been observed that it will, when introduced into the 
intestinal tract in large numbers, check the growth and thereby 
greatly lessen the number of other organisms in it. Butter- 
milk is therefore especially useful to lessen fermentation in the 
intestines. 

Of late years it has been largely used because Metchnikoff 
has praised it as an elixir of long life. He believes that arterio- 
sclerosis and the lesions caused by it are due to bacterial fer- 
mentation of food products in the intestines and he urges the 
drinking of buttermilk or the taking of lactic acid ferments to 
prevent this. 

However, there is not sufficient positive experimental evi- 
dence to show that lasting effects of this kind can be produced 
by the lactic acid ferments or by the Bulgarian bacillus 
especially. Moreover there is some evidence to prove that 
certain micro-organisms are needed in the intestines to com- 
plete digestion, and therefore to maintain good health. 

Cheese is a product of milk and is composed of its casein and 
fat. The casein is precipitated either by permitting the milk 
to sour or by adding acids or rennet to it. Cheeses vary in 
composition according as they are made of milk to which cream 
has been added, of whole milk, or of skimmed milk. In this 
way the relative quantity of fat that they contain is made to 
vary. They are modified in consistence according as the curd 
is pressed into hard cakes or left as a soft mass and shaped by 
the hand of the maker or by light pressure. The peculiar 
flavor of cheese is due to special micro-organisms that, by their 
growth during the period of 'ripening,' develop in it chemical 
bodies of peculiar flavor. 

The soft cheeses, such as cream cheese, Brie, Camembert, 
Neufchatel, and Stilton, must be eaten fresh, as they will not 
keep long. 



86 ANIMAL FOODS. 

The hard cheeses, such as American dairy, Parmesan, and 
Edam, will keep for a long time. 

With few exceptions cheese is made from cow's milk. Par- 
mesan is made from goat's milk partly skimmed, and Roquefort 
from the milk of the ewe. 

The following table, taken from Hutchison, shows the com- 
position of many of the common cheeses : 1 

Nitrogenous 
Cheese. Water Matter Fat Ash 

American 26.9 32.9 3 1 >° 4.5 

Brie 49.7 18.9 26.8 4.5 

Camembert 48.6 21.0 21.7 4.4 

Cheddar 31.9 33.4 26.8 3.9 

Cheshire 33.2 29.4 30.7 4.3 

Cream 32.0 8.6 35. 9 1.5 

Dutch 32.9 30.8 17.8 6.3 

Gloucester 3 x -9 36.7 24.7 4.4 

Gorgonzola 39. 2 25.9 29.9 4.7 

Grueyere 34.1 31.5 28.2 4.0 

Neufchatel 41.0 *4-3 43-2 1.4 

Parmesan 30.0 43.8 16.5 5.9 

Roquefort 25.1 34.8 31.5 5.5 

Stilton 27.6 23.9 38.9 3.1 

In general it may be said that cheese contains approximately 
one-third water, one-third nitrogenous matter, and one-third 
fat. It would seem to be a most concentrated and cheap 
nitrogenous food. A pound of lean meat contains over 70 
per cent, of water. Mattieu Williams says that a cheese of 
twenty pounds contains as much nutriment as a whole sheep 
weighing sixty pounds. A pound of cheese will produce at 
least 2000 calories. This is more than three times as much as 
a pound of lean beef will yield. 

Although, from its composition, cheese appears to be so 
perfect a nitrogenous food, it illustrates well the fact that the 
value of articles of food cannot be estimated by their composi- 
tion alone. Cheese is not easily digested. The fat that it 
contains surrounds the particles of casein of which it is chiefly 
composed and prevents the gastric juice from coming readily 

1 For a full description of all of the many kinds of cheese and their composition, see 
"Varieties of Cheese," Bulletin 146, U. S. Department Agriculture, Bureau of Animal 
Industry, 1911. 



TYROTOXICON POISONING. 87 

in contact with them. Cheese is most easily digested when it 
is eaten in a state of fine subdivision or in solution, as recom- 
mended by Williams. It can be readily dissolved by a small 
amount of potassium bicarbonate. A savory and nutritious 
dish can be prepared by adding milk and eggs to this dissolved 
cheese. 

Certain cheeses contain fatty acids that are developed in the 
process of ripening. They are frequently irritating to the 
stomach. 

Cheese, like other milk products, may contain tyrotoxicon 
and cause even fatal poisoning. This ptomain is the product of 
a specific micro-organism which sometimes infects milk and its 
products without materially modifying their appearance or 
taste. 



CHAPTER VII 
ANIMAL FOODS (Continued) 

Eggs. Meats. Cooking. Meat Products. Digestibility. Food 
Value. Fish. 

EGGS 

Hens' eggs are a complete food in the sense that they contain 
some of all the ingredients that are essential in foods. On 
account of the small quantity of carbohydrate in them, they 
are, however, inadequate. An average egg will yield seven 
grams of protein; it would, therefore, take from ten to 
twenty of them to supply the amount requisite for one man 
for one day. They are, however, among the most important 
articles of food, for they are bland, easily digested, and capable 
of being prepared in a great variety of appetizing ways. 

The composition of the edible part of a hen's egg is: 

Water 73-7 per cent. 

Protein 14.8 per cent. 

Fat 10.5 per cent. 

Salines 1 . o per cent. 

The average weight of an egg is forty-four grams, and it will 
generate seventy calories. The white and the yolk differ con- 
siderably in composition, as the following analysis shows : 

Shell. ... 10 parts, average weight 6 grams, carbonate of lime. 
Yolk. . . .30 parts, average weight 15 grams, Protein. . . 16.0 per cent. 

Fat 30.7 per cent. 

Salts 1.3 per cent. 

Water .... 52.0 per cent. 

100. o 
White. . .60 parts, average weight 29 grams, Protein. . . 20.4 percent. 

Salts 1.6 per cent. 

Water.... 78.0 percent. 



ss 



DIGESTIBILITY OF EGGS. 89 

The protein of the white is commonly called egg-albumen, 
but it is not a simple substance. Eicholz has shown that some 
of the molecules contain a carbohydrate component. Fat is 
not found in the white of egg. In the yolk the fat consists of 
palmitin, stearin, olein, and such bodies as cholesterin and 
lecithin, which are frequently grouped with the fats because, 
like them, they are soluble in ether. Nuclein is one of the most 
important albumins of the yolk. It carries a part of the phos- 
phorus which eggs contain. The salts in eggs are the most 
important ones needed by man's tissues. Moreover, they 
contain an assimilable iron in relatively large quantity. When 
cooked, the albumin of the egg is more or less coagulated. 
When cooked completely, it forms a firm, solid, semielastic 
mass that is not readily attacked by the digestive juices unless 
it is finely divided. 

The following table compiled from Penzoldt is interesting, 
as it throws light upon the gastric digestibility of different 
culinary preparations: 

Two eggs soft boiled leave the stomach in 1 3/4 hours. 

Two eggs raw leave the stomach in 21/4 hours. 

Two eggs poached and five grams of 

butter leave the stomach in 2 1/2 hours. 

Two eggs hard boiled leave the stomach in 3 hours. 

Two eggs as omelet leave the stomach in 3 hours. 

Apparently this table does not accord with popular experi- 
ence, which assigns the greatest digestibility to raw eggs. 
The observations of Burke explain the discrepancy. Raw eggs 
are apparently so bland that they do not excite either gastric 
secretion or motion, and are ultimately passed into the duo- 
denum almost unchanged. This, of course, will not be so true 
if they are taken with other foods, as bouillon, or milk. Hard- 
boiled eggs become comparatively digestible when they are 
minced finely and mingled with water in the stomach. Such 
an egg will disappear from the stomach as quickly as a soft- 
boiled one. 

Eggs are absorbed very completely from the intestine, leaving 
a residue of only about 5 per cent. 
Modes of Administration 

Raw eggs can be given directly from the shell, or seasoned 



90 ANIMAL FOODS. 

with pepper or salt, or added to bouillon, to coffee, or to milk. 
A very palatable preparation is made by shaking an egg 
thoroughly with lemon- juice and sugar, and diluting the 
mixture with either plain or carbonized water. 

Egg-nog is made by shaking an egg with milk and flavoring 
the mixture with wine or distilled liquor. An agreeable, 
equally nutritious mixture can be made by omitting the alcoholic 
and flavoring with cinnamon, nutmeg, or other spice. Custards 
are made with egg and milk, sweetened, flavored, and cooked. 
These and boiled and poached eggs are the forms in which they 
are usually served to invalids. Eggs are, however, often used 
in other dishes and in cakes of various kinds. 

When digestion is slow, eggs are often modified before they 
are completely prepared for absorption. Hydrogen sulphid 
and ammonia are set free from them. The former especially 
may escape from the stomach with other gases and be readily 
detected by its characteristic odor. This is always a sign that 
the eggs are not being perfectly digested. Somewhat similar 
changes take place when they spoil from long keeping. Eggs 
that are not fresh should never be served, and especially not to 
an invalid. 

There are a few persons who cannot eat eggs because the 
eructation of sulphureted hydrogen generated by their imper- 
fect digestion makes them distasteful. There are a few others 
who are made quickly and violently ill whenever they eat eggs ; 
an idiosyncrasy that cannot be accounted for, and that has 
given rise to the popular expression that eggs are 'bilious/ 

MEATS 

Meats are among the most important articles of diet. From 
them man obtains the largest part of his protein food. 

Meat flavors are especially savory and excite a flow of saliva 
and gastric juice. Raw meat, if it is finely divided or thoroughly 
masticated, is readily digested. It is not so palatable as 
cooked meat, and is therefore rarely eaten by civilized people. 

Cooking effects several changes in meat: it causes a loss of 
water, a loss of fat, a loss of extractives, and, by gelatinizing 
the connective tissue, which then becomes soluble, loosens the 



COOKING OF MEAT. 9 1 

fibers of the flesh so that they fall apart and are readily reached 
by the digestive juices. The change effected in the color of 
the meat renders it more agreeable to the eye of the diner, and 
the modification of its flavor is more agreeable to the taste. 

It is not necessary here to discuss in detail methods of cook- 
ing, but the processes should be understood sufficiently to 
comprehend their purpose. Meat may be boiled by placing it 
in cold water and subjecting it to moderate heat for a long time. 
Before the temperature of the water is much elevated the greater 
part of the salts, of the juice, and of the extractives or flavors 
of the meat will be dissolved. As the flesh is subsequently 
cooked through by the greater heat of the water in which it is 
placed, the fiber becomes gray in color, the connective tissue 
being gelatinized and partly dissolved so that the meat readily 
falls to pieces. It is, however, quite tasteless, although not 
lacking in nutritive properties. The flavoring is in the fluid 
in which the meat has been cooked. This is the proper way 
to stew meat when moderate quantities of water are used and 
the meat is cut into small pieces before being placed in it. 
The meat and the fluid in which it is cooked are then eaten 
together. This makes a savory and easily digested dish. But 
if a large mass of meat is to be cooked in water, the water should 
be boiling before the meat is put into it. The albumin of the 
superficial fibers will be at once coagulated and will seal the 
juices in the meat. The water should then be allowed to cool 
so that it is at about 180 F. instead of 212 F., and should be 
kept at this temperature until the mass of flesh is thoroughly 
cooked. By this process the meat will be stewed in its own 
juices, which are retained in it. 

When meat is roasted after the modern fashion, it is placed 
in a very hot oven. The hot air about it rapidly coagulates 
the superficial fibers and therefore prevents the escape of the 
juices. It should then be kept for a considerable time at a 
somewhat lower temperature. Large pieces, such as joints and 
large roasts, should be frequently basted by pouring over them 
the fat and juices that accumulate in the dish. This helps to 
seal the meat more thoroughly and to retain the largest part 
of the juice. It also causes chemical changes that modify the 
flavor. 



92 ANIMAL FOODS. 

The olden English fashion of roasting was to place the meat 
upon a spit before the grate and turn it continuously so that 
each portion of the periphery was successively exposed directly 
to the heat. Broiling or grilling over an open fire is essentially 
the same process, but the portion of meat is small in size and 
is cooked through at once. Exposure to very hot air coagu- 
lates the albumin upon the surface, and the juices within 
help both to cook the inner fibers and to cause the whole 
to swell slightly. The inner fibers are juicy and particularly 
savory. 

Frying, as it is ordinarily practised, is not properly managed. 
It is customary to put a small quantity of fat or oil in a shallow 
dish over a hot fire; just enough is used to prevent the food 
from sticking to the dish. When it is melted and simmering, 
the meat is put in the dish, cooked quickly upon one side, turned 
and cooked upon the other; if it is small, turning is not con- 
sidered necessary. The surface of the meat is seared in the 
hot fat, but as it is not immersed in it, this is done unevenly. 
Some of the fat penetrates and often saturates it. The hot fat 
is partly decomposed, and fatty acids are liberated that irritate 
the stomach when the meat is eaten. The fat that permeates 
the meat prevents the ready access of the gastric juice to the 
fibers, and therefore makes their digestion slow. The correct 
method of frying is the following: A deep dish full of oil is 
heated to boiling, which means that the oil is at a temperature 
of from 350 to 380 F.; and the meat to be fried is immersed 
in this boiling oil. The surface is at once completely seared, 
the superficial albumin coagulated, the mass made impermea- 
able and doubly so because the particles of water attempting 
to escape from the meat keeps it surrounded by a layer of 
steam. Immersion in the extremely hot fat cooks the food 
with rapidity. If it is removed from the oil as soon as it is 
cooked and permitted to drip, it is not excessively fat and not 
nearly so indigestible as what is ordinarily called fried food. 

Meat is made most savory by roasting or broiling. It is most 
digestible when properly stewed, and least so when fried. All 
meats retain their flavor and their juiciness when the surfaces 
are rapidly coagulated by high temperature and the interior 
slowly cooked at a much lower temperature. Roasting accom- 



BOUILLON. 93 

plishes this well, although boiling can be made to do so when 
it is carried out correctly. 

The flavor of meat varies with the species of animal from 
which it is derived. It is most distinct and characteristic in 
mature animals, and especially in those that have led an active 
life. The food habitually taken by an animal modifies the 
flavor of its flesh. The difference thus produced is especially 
noticeable in ducks fed only upon grain, and in ducks fed partly 
upon fish. The flesh of the latter retains a distinct taste of fish. 
When animals first are killed, their meat is less savory than 
when kept for some time in a cool place. By keeping, changes 
are produced in it. The albumin partly coagulates, lactic acid 
forms in the muscle and modifies part of the albumin, making 
it somewhat more soluble, and rendering the whole more ten- 
der. Except in the tropics, where meat cannot be kept long, 
it is customary to keep it in cold rooms for some time, both 
that a richer flavor may develop in it and that it may become 
tender. 

Bouillons are made by soaking finely cut meat for a time in 
water so that the extractives, the salts, and a little gelatin 
may be dissolved out. It is then slowly heated and cooked 
and finally brought quickly to a boil. When the liquid is 
poured off, it is rich in meat flavor, but contains little nutri- 
ment. If it is allowed to cool, fat will accumulate upon the 
surface. This should be skimmed off. The remainder will be 
found to consist of two layers — the upper and thicker of clear 
fluid, the lower of a turbid fluid. The turbidity of the latter 
is due to minute particles of coagulated albumin, which is 
almost the only nutrient material in it. If a clear bouillon or 
soup is prepared, this is strained off. The liquid that is swal- 
lowed contains only a minute amount of protein. Although it 
is not nutritious to an appreciable extent, it is agreeable to the 
taste, often whets the appetite, and promptly stimulates the 
secretion of gastric juice. It is, therefore, an excellent intro- 
duction to a more solid meal. If soup is to constitute the chief 
dish at a meal, it should be made more nutritious by the addi- 
tion of vegetables or cereals or by stirring into it an egg. From 
such a thick soup the particles of coagulated albumin should 
not be strained off as they are when a clear bouillon is made. 



94 ANIMAL FOODS. 

Beef-tea, mutton broth, chicken broth, and similar prepara- 
tions so frequently given to invalids are bouillons and especially 
poor in nutrient ingredients. They should be used only to 
whet the appetite and to act as feeble stimulants. When sipped 
as hot drinks, as coffee, tea, and even hot water, they will make 
the heart beat stronger and faster. The salines that broths 
contain are sometimes useful. The extractives or flavorings 
are not nutritious. They are mostly waste-products that are 
eliminated by the kidneys during the life of animals, and if 
they are eaten, must similarly be gotten rid of by man. They 
may thus in some cases act partially as diuretics, but under 
some conditions of renal failure may become toxic. 

Beef-extracts, such as Liebig's, are concentrated bouillons, 
and when eaten, are diluted to the consistence of broth. Their 
composition and value are the same. Liebig's extract con- 
tains approximately 30 per cent, of protein and gelatin. When 
made into beef-tea, a pint of the latter will contain less than 
thirty grains of these ingredients. The experiment of starving 
one set of animals and of feeding another upon beef-extract 
has been made, with the result that both died in the same length 
of time. So thoroughly are medical men convinced of the in- 
significant food value of bouillons and beef-extracts that it is 
hardly necessary to emphasize the fact. They are still, how- 
ever, household panaceas. 

Beef -juice is made at home by lightly broiling a thick, juicy 
steak, cutting it into fine pieces, and squeezing it in a lemon- 
squeezer or, better, in a meat press. The extractives, the blood, 
and some of the proteins of the meat are thus extracted. Round 
steak can be made to yield nearly 7 per cent, of coagulable pro- 
tein. If finely chopped raw meat is heated in a bottle kept for 
two or three hours in hot water, from 2 to 3 per cent, of coagu- 
lable protein can be extracted. Care must be taken not to 
boil the juice or heat it greatly, or the albumin in it will coagu- 
late and will be precipitated. The commercial beef-juices, 
such as Valentine's, Wyeth's, and Armour's, are made by sub- 
jecting chopped meat to a strong pressure. The juice that is 
thus obtained is concentrated in vacuo to prevent coagulation 
of its protein. These preparations contain from about 2 to 30 
per cent, of protein; most of them, from 4 to 5 per cent. 



MEAT EXTRACTS. 



95 



The following table of commerical extracts will give informa- 
tion as to the percentage of nutrients and some other important 
ingredients: 1 

SOLID MEAT EXTRACTS 



Water 



Total 
Ash 



Total 


Total 


Nitro- 


Pro- 


gen 


teins 


% 


% 


7-30 


22. 12 


9.07 


30.50 


7.66 


27.51 


6.02 


14.93 


6.60 


15.38 


6.86 


15.01 



Kreatin 

AND 

Kreat- 

ININ 



Xan- 

THIN 



Am- 
monia 



"Rex" brand beef ext 
Liebig's ext. of meat. . 
Armour's ext. of beef. 
Ext. of beef, Premier. 

Beef extract 

Beef ext. , Coin Special 



26.50 
21 . 14 
21.66 
21.86 
20. 16 
12.39 



24.06 
2 1 . 03 
20.46 
30.92 
27.28 
31.68 



% 
1.03 
0.08 
o. 11 
0.30 
1.22 
1. 41 



% 

0.24 
o.45 
0.26 
0.52 
0.86 
0.30 



FLUID MEAT EXTRACTS 



Concentrated fluid beef ext. 

Beef juice 

Meat juice 

Vigoral 

" Rex "fluid beef ext 

Fluid ext. of beef 

Fluid beef jelly 



57-75 


17.23 


2.85 


6.76 


58.84 


16.21 


3.15 


6.45 


57.64 


10. 26 


3.06 


5.63 


49.94 


15-91 


3.87 


io.75 


55-99 


16.99 


3-95 


7.00 


64.63 


16. 13 


3.18 


10.25 


68.97 


13.85 


2.41 


8.13 



1. 19 

0.81 

1.09 

1.50 

2.50 

1.56 
0.81 



0.62 

0.71 
0.60 
0.46 

O. II 

0.24 



0.13 
0.24 
0.27 
0.16 
0.24 
0.22 
o. 16 



MISCELLANEOUS PREPARATIONS 



Bouillon capsules 

Bovril, seasoned 

Beef jelly, Mosquera ext. of 
beef 

Essence of beef 

Predigested beef 

Soluble beef 

Bo vox essence of beef 

Johnsons' fluid beef 

American brand ext. of beef . 

Bovinine concentrated beef.. 

Essence of Mutton 

Liquid food (ext. of beef, 
mutton, and fruits) 

Maggi's bouillon 

Peptonized beef. Rose 

Beef ext. and vegetable 
tablets 

Leube-Rosenthal's beef solu- 
tion 

Malted Meat ext. of beef 

Beef peptonoids 



14.75 


39-75 


5-93 


22. 19 


43.39 


16.09 


562 


22.06 


27.82 


I7.3I 


7.83 


28.63 


90.93 


1-34 


1.28 


5.07 


91.69 


0.18 


0.42 


1. 19 


30.15 


14-55 


8.41 


37.76 


65.77 


17.29 


3v7i 


16.57 


47.22 


9.80 


6.57 


3L75 


27.54 


34-73 


5.63 


26.69 


80.40 


1.55 


2.36 


14.14 


82.03 


2.25 


2.61 


12.00 


86.09 


0.65 


1.84 


10.69 


56.56 


21.94 


2.76 


2.13 


45-13 


3.52 


6.98 


22.20 


22.29 


23.66 


4. 10 


18.87 


72.68 


3.91 


3.13 


16. 13 


8.61 


7.87 


2.02 


9.82 


5.72 


5. 63 


4.12 


23.32 



1.44 

1. 59 

1. 81 
o.34 
0.06 
1. 3i 
0.16 
0.62 

None. 
0.53 

None. 
0.22 
0.22 

0.47 
0.25 

Trace. 
Trace. 



0.35 
0.43 

o. 14 
0.03 
0.03 
0.60 
0.03 
0.49 
0.08 
0.08 

O. II 

0.08 

O. II 

0.27 

0.43 
0.03 

0.05 

O. II 



o. 19 
o. 19 

0.35 
0.05 

O.OI 

0.28 
0.21 
0.30 
0.25 

O.OI 

0.15 

0.06 
0.67 
0.32 

0.08 
0.15 

0.00 
0.00 



1 Compiled from Bulletin No. 114, Bureau of Chemistry, U. S. Department of Agriculture 



96 ANIMAL FOODS. 

White of egg contains 12 per cent, of egg-albumen. It is, 
therefore, much more nutritious than most of these juices and 
much less expensive. Meat juices have, however, both a positive 
and a negative value. Like bouillon, they often whet the appe- 
tite of invalids and excite the stomach to greater work. When 
bread, crackers, or rice are soaked in them, they make an agree- 
able dish and one that is nutritious. They should, therefore, 
be regarded as adjuncts to more nutritious food, and not as 
staple articles of diet. Their negative value in those cases of 
illness in which food must necessarily be withheld for a time, 
is that they permit ' nourishment ' to be given that satisfies the 
family and does not materially harm the patient. Their use as 
temporary stimulants will be set forth in another connection. 

Meat powders of various kinds are upon the market and are 
more or less useful to strengthen or increase the nutritive value 
of other foods. Beef powder can readily be made by drying 
boiled beef upon a water-bath and powdering it in a cofle-mill. 
The powder thus made can best be given in chocolate or milk. 
It is useful when it is necessary to administer food in a concen- 
trated condition. 

Mosquera's beef meal is a powdered beef that has been partly 
digested by pineapple juice. Somatose consists chiefly of albu- 
moses. A variety of 'peptone' preparations in powder form, or 
predigested powdered meat, are upon the market. Some of 
them are also offered in liquid form with and without alcohol. 
The following analyses of certain preparations tabulated by 
Hutchinson make plain the general nutritive value of the class : 

Preparations Water 

Koch's peptone 40 . 16 

Liebig's peptone 3 1 . 90 

Brand's peptone 84 . 60 

Denaeyer's peptone 78 .45 

Darby's fluid meat 25.71 

Armour's wine of peptone .... 83 . 00 

Fairchild's panopepton 81 . 00 

Carnrick's peptonoids consist chiefly of starch and milk-sugar. 
Meat jellies are agreeable, especially during convalescence 



Soluble Pro- 
teins, Chief- 
ly Albu- 
moses 


Extractives 
and Nonpro- 
tein Organic 
Matter 


Mineral 
Matter 


33-78 


15-93 


6.89 


33-40 


24. 60 


9.90 


7 .00 




1 .40 


12.15 


4-3 2 


2-54 


30.60 


30.18 


I3.50 


3.00 


12 . 90 


1 . 10 


3.00 


1 5 . 00 (largely 1 . 00 




sugar) 





DIGESTIBILITY OF MEAT. 9 

from illness, and are slightly nutritious. Their basis is gelatin. 
Glue is a crude form of gelatin. Its purest form is isinglass, 
which is obtained from the swim-bladders of fishes. The con- 
nective tissue of young animals is especially rich in it. Calves, 
feet when boiled yield 25 per cent, of gelatin and a little more 
than 11 per cent, of fat. Gelatin jellies, whether flavored with 
meat, fruit, or wine, rarely contain more than 2 per cent, of it. 
Gelatin is very soluble and easy to digest. It is not, as was 
explained in a former chapter, a builder of tissue as are proteins, 
but it possesses about the same power to produce energy. It 
is a protein sparer — that is, it prevents protein waste. It is 
estimated that it will save half its weight of tissue protein. It 
has been calculated that not more than twenty-five or thirty 
grams of gelatin can conveniently be taken in a day, and rarely 
more than a small fraction of this is eaten. If the former 
quantity were taken, it would effect a saving of only a little more 
than an ounce of flesh. Its value in fevers as a protein saver is 
therefore slight. 

Fish is an economic kind of protein food. It is for the most 
part easy of digestion. The fat fishes, such as salmon, are less 
digestible than those whose flesh is of shorter, smaller fiber and 
less rich in fat. Fish is highly nutritious, but because it con- 
tains more water than most other meats it is weight for weight 
of less nutritive value. Lobster and crab meat are relatively 
indigestible because they are coarse and tough. 

The oyster is the most highly prized shell-fish. When raw, 
it is more digestible than when cooked. It is nutritious and 
wholesome unless, as in some cases, contaminated with typhoid 
bacilli. It contains about 6 per cent, of nitrogenous matter, 
1.5 per cent, of fat, and 3.3 per cent, of glycogen. A dozen 
oysters contain only about one ounce of solid matter. They 
therefore contain nourishment in a very diluted form and are 
not an economic food. 

Digestibility 

The digestibility of meats is estimated sometimes by the 
relative length of time that it takes artificial gastric juice to 
digest different kinds; sometimes, and more perfectly, by 
7 



98 ANIMAL FOODS. 

experimentally determining how long different kinds remain in 
a healthy stomach. The table on the opposite page, which has 
been compiled from various authors, will give an idea of the 
relative digestibility of different kinds. 

Penzoldt's figures illustrate well the fact that small quantities 
of a given substance are digested by the stomach more rapidly 
than large ones. This emphasizes the need of small meals when 
digestion is impaired. The comparatively slow digestion of 
pigeon and young chicken is surprising, as they are usually 
believed to be easy for the stomach to dispose of. This calls 
attention to the fact that, when the stomach is weak, there are 
other factors to be considered in prescribing foods for it, than 
their relative rapidity of digestion. Pigeon and chicken are 
bland and, provided they are not eaten in too large quantities, 
cause little discomfort, because they contain very little fat, and 
the muscle-fibers are relatively short and small. Sweetbreads 
are digestible and bland. They are composed of gland cells 
held together by a loose and delicate connective-tissue frame- 
work. Nine ounces are completely disposed of by a healthy 
stomach in two and three-quarter hours. Liver and kidney are 
compact organs with a relatively small amount of connective 
tissue. They are slow to digest unless finely minced before 
they are eaten. Calf's brain is readily disposed of by the 
stomach, but it is very imperfectly digested and absorbed by 
the intestines, for more than 40 per cent, appears in the feces. 
Fish and oysters are bland and easy of digestion. Fish of 
coarse fiber, and fat, such as salmon, is relatively slow and 
difficult for the stomach to dispose of. Three and one-third 
ounces of boiled salmon are modified and delivered into the 
intestine by the stomach in from three to four hours, while 
twice this amount of boiled pike or carp are similarly disposed 
of in from two to three hours. Three oysters of average size are 
digested by the stomach in one and three-quarters hours, and 
two and one-half ounces in from two to three hours. 



Composition 

It is unnecessary to discuss the physical attributes of different 
kinds of meat. They are familiar. The composition of the 



DIGESTIBILITY OF MEAT. 



99 



Boiled milk, 

Bouillon, 

Eggs, raw, 

Milk, 

Pigs' feet, 

Trout, 

Calf's brains, boiled, . . . 

Boiled milk, . . ... 
Eggs, hard boiled or omelet, 
Beef sausage, raw, .... 

Brains, boiled, 

Sweetbread, 

Oyster, raw, 

Carp, boiled, 

Pike, boiled, 

Sharper, boiled, 

Beef, raw, chopped fine, . 
Beef, half cooked, .... 
Beef, well cooked, .... 
Beef, thoroughly roasted, . 

Mutton, raw, 

Veal, cooked, 

Pork, cooked, 

Mutton, roasted, .... 

Beefsteak, 

Ham, cooked, 

Lean beef, broiled, .... 

Fish, boiled, 

Bacon, roasted, 

Poultry, 

Veal, 

Codfish, boiled, 

Chicken, young, boiled, . . 
Partridge, roasted, .... 

Pigeon, boiled, 

Beef, cooked, 

Calf's foot, boiled, .... 

Ham, raw, 

Beefsteak, raw, grated, . . 

Salmon, boiled, 

Caviar, 

Herring, pickled and 

smoked, 

Pigeon, roasted, 

Fillet of beef, roasted, . . 
Beef tongue, smoked, . . 

Bacon, 

Hare, roasted, 

Partridge, roasted, .... 

Goose, roasted, 

Duck, roasted, 



Penzoldt. 



I to 2 hrs. ioo to 200 grams 

tt n 2OO " 

" " IOO " 



2 to 3 hrs. 300 to 500 g 

" IOO 

" " IOO 

it «. 2 £ 

" " 250 

" « 72 

u ti 200 

" " 200 

« " 200 



3 to 4 hrs. 100 grams 



100 



160 



2 to 3 hrs. 200 

3 to 4 " 230 
" 230 
" 250 
" 250 
" 250 
" 160 

" IOO 

" IOO 

" 72 

" 200 

to 5 hrs. 210 

" 250 

" 250 

" IOO 

" 250 

" 240 

" 250 

« 280 



Jesskn. 



2 hrs. 
2)4 hrs, 
3 

4 

2 

2K 

3 



RlCHERT 



2 tO 3 

hrs. 
30 to 60 
minutes 
I hour 



B EAU- 
MONT. 



y 2 hrs. 



13/ 



hours 



IOO ANIMAL FOODS. 

meat of different animals and of different cuts of the same animal 
should be known, and it is fully given in the following tables, 
compiled by Charles D. Wood 1 and C. F. Langworthy. 2 It 
must be remembered that the composition as given is an 
average, for different analyses vary greatly. This is due in 
part to the variable amount of fat contained in meat, in part 
to the varying amount of work that animals do, and often 
largely to the relative dryness of meat. The following analyses 
of beef from New Mexico with table comparing the analyses 
made in other States of the Union, show how great may be the 
variations from climatic causes: 

Refuse Water Protein Fat Pp _ a ,_ p . r 

Per Per Per F rw fW 

Cent. Cent. Cent. Cent - Cent - 

Maine 16.1 50.2 14.4 18.6 0.7 

Tennessee 20.4 52.9 *5-3 IO -5 °-8 

Texas 20.0 55-2 15.3 8.8 0.7 

New Mexcio 30 .7 51.1 16.6 0.7 0.9 

Any one desiring a more elaborate presentation of the subject 
of the analyses of meats than these tables give should consult 
such a work as that of C. Ainsworth Mitchell on " Flesh Foods." 

1 " Meat Composition and Cooking," Farmers' Bulletin No. 34, United States Department 
of Agriculture. 

2 "Fish as Food," Farmers' Bulletin No. 85, United States Department of Agriculture. 



COMPOSITION OF MEATS. 



IOI 



TABLE SHOWING THE CHEMICAL COMPOSITION AND FUEL VALUE 
PER POUND OF MEATS. 



Kind and Cut of Meat. 









Nl 


TTRIEN 


TS. 




Fuel 














Refuse. 


Water. 


Water- 
free 
sub- 
stance. 


Pro- 
tein. 


Fat. 


Carbo- 

hy- 
drates. 


Ash. 


Value 

PER 

Pound. 


Per cent. 
14-3 


Per cent. 
47-4 
40.6 


Per 
cent. 
52.6 
45-1 


Per 
cent. 
14.6 
12.5 


Per 
cent. 
37-2 
3i-9 


Per 
cent. 


Per 

cent. 

0.8 

0.7 


Cal- 
ories. 
1840 
1580 


17.0 


67.8 

56.3 


32.2 

26.7 


19.0 
15-7 


12.3 
10.2 




0.9 
0.8 


870 
720 


i' 3 '.8 


57-3 
49-3 


42.7 
36.9 


17.4 
15.0 


24.4 
21. 1 




0.9 
0.8 


1355 
1 170 


6.6 


59-3 
55-5 


40.7 
37-9 


17.6 

:i6. 5 


22.2 
20.6 




0.9 
0.8 


1260 
"75 


13-0 


60.5 
52.6 


39-5 
34-4 


18.3 
15-9 


20.2 

17.6 




1.0 
0.9 


1190 
1040 


27 '.6 


634 
45-9 


36.6 
26.5 


19.2 
13-9 


16.5 

II <3 




0.9 
0.7 


1055 
760 


14.7 


52.7 
44-9 


47-3 
40.4 


15-4 
131 


3i-i 
26.6 




0.8 
0.7 


1600 
1365 


20.8 


55-4 
43-8 


44.6 
35-4 


16.9 
13-4 


26.8 
21.3 




0.9 

0.7 


1445 
1150 


12.2 


43-9 
38.6 


56.1 
49.2 


13-7 
12.0 


41.6 
36.5 




0.8 
0.7 


2010 
1765 


7-7 


65.8 
60.7 


34-2 
31-6 


19.7 
18.1 


12.6 




1.0 

0.9 


935 
870 


32.1 


69-5 
47.2 


30.5 
20.7 


20.6 
14.0 


8.6 

5-8 




1.3 

0.9 


745 
505 


21.4 


56.7 
44-5 


43-3 
34-1 


16.8 
13.2 


25.6 
20.2 




0.9 
0.7 


1395 
1095 


36.9 


67.9 
42.9 


32.1 
20.2 


19.6 
12.3 


11.6 
7-3 




0.9 
0.6 


855 
535 


53-9 


67.8 
31-3 


32.2 
14.8 


19.8 
9-i 


"•5 
5-3 




0.9 
0.4 


855 
395 


16.4 


68.3 
56.8 


3i-7 
26.8 


19.3 
16. 1 


"•3 
9.8 




I.I 

0.9 


835 
715 


19.4 


61.4 
49-5 


38.6 
311 


17-5 
14.1 


20.2 
16.3 




0.9 
0.7 


1 180 

950 


15.8 


61.0 
51-3 


39-0 
32.9 


18.0 

15-2 


20.1 
17.0 




0.9 
0.7 


1 185 
1000 



BEEF. 

Brisket : 

Edible portion, . 

As purchased, . 
Chuck, with shoulder 

Edible portion, . 

As purchased, . 
Chuck ribs : 

Edible portion, . 

As purchased, . 
Flank : 

Edible portion, . 

As purchased, . 
Loin : 

Edible portion, . 

As purchased, . 
Neck : 

Edible portion, . 

As purchased, . 
Plate : 

Edible portion, . 

As purchased, . 
Ribs: 

Edible portion, . 

As purchased, . 
Ribs, cross : 

Edible portion, . 

As purchased, . 
Round : 

Edible portion, . 

As purchased, . 
Round, second cut : 

Edible portion, . 

As purchased, . 
Rump: 

Edible portion, . 

As purchased, . 
Shank, fore: 

Edible portion, . 

As purchased, . 
Shank, hind : 

Edible portion, . 

As purchased, . 
Shoulder and clod : l 

Edible portion, . 

As purchased, . , 
Fore quarter : 

Edible portion, . , 

As purchased, . , 
Hind quarter: 

Edible portion, . . 

As purchased, . , 



1 The clod itself has no bone — i. e, refuse. 



102 



COMPOSITION OF MEATS. 



Table Showing the Chemical Composition and Fuel Value per Pound of 
Meats. — ( Continued. ) 



Kind and Cut of Meat. 



Refuse. 







Nutrients. 




Water. 


Water- 
free 
sub- 
stance. 


Pro- 
tein. 


Fat. 


Carbo- 

hy- 
drates. 


Ash. 


Per cent. 
60.6 
49-7 
69.8 


Per 
cent. 
39-4 
32.0 
30.2 


Per 
cent. 
17.7 
14.5 
21.6 


Per 
cent. 
20.8 
16.8 
5-4 


Per 
cent. 

i"8 


Per 
cent. 
0.9 
0.7 
1.4 


53-i 


46.9 


28.5 


14.0 




4.4 


50.9 
40.0 


49.1 

38.6 


18.7 
14.7 


24.7 
19.4 




5-7 
4-5 


49-9 
43-7 


50.1 
44.2 


14.2 
12.4 


33-o 
29.2 




2.6 


40.1 
34-3 


59-9 
51.2 


13-3 
11.4 


£3 




4-7 
4.0 


58.1 
54-5 


41.9 
39-5 


15-3 
14.4 


23-3 
22.0 




3-3 
3-i 


50.8 


49.2 


31-8 


6.8 


0.6 


10.0 


51-3 


78.7 


21-5 


23.2 




4.0 


49-9 
62.3 


50.1 
37-7 


21.0 
12.5 


25.1 
20.5 




4.0 

4-7 


66.4 

527 


33-6 
26.7 


18.8 
14.9 


13-8 
11.0 




1.0 

0.8 


73-3 

59-5 
68.9 


26.7 
21.6 
3" 


19.2 

15.6 
19.7 


6-5 

5-2 

10.4 




1.0 

0.8 

1.0 


70.4 
59-4 


29.6 
25.0 


20.1 
16.9 


8.4 
7.2 




I.I 

0.9 


68.3 
65.6 


31-7 
30.4 


20.8 
20.0 


9.9 

9-5 




1.0 

0.9 


69.2 

57-2 


30.8 
25-5 


19.4 
16.0 


10.4 
8.6 




1.0 

0.9 


72.6 

49-9 


27.4 
18.6 


19-5 
13-3 


4.6 




1.0 

0.7 


72.5 
53-0 


27.5 
20.1 


20.2 
14.7 


6.2 
4.6 




I.I 

0.8 


62.6 
43-7 


374 
26.1 


20.1 
14.0 


16.2 
"•3 




I.I 

0.8 


74.0 
44.1 


26.0 

15-5 


19.8 
11.8 


52 
31 




1.0 

0.6 


74-5 
27.8 


25.5 
9-5 


19.9 
. 7-4 


4.6 

i-7 




1.0 

0.4 


71.7 
54-2 


28.3 
21.3 


19.4 
14.6 


8.0 
6.0 




0.9 
0.7 



Fuel 
Value 

per 
Pound. 



beef. 
Side: 

Edible portion, 

As purchased, 

Liver, as purchased, 

Cooked, corned, and canned, 

as purchased, 

Corned brisket : 

Edible portion, 

As purchased, 

Corned flank : 

Edible portion, 

As purchased, 

Corned plate : 

Edible portion, 

As purchased, 

Corned rump : 

Edible portion, 

As purchased, 

Dried and smoked, as pur- 
chased, 

Tongue : 

Canned, whole, as pur- 
chased, 

Canned, ground, as pur- 
chased, 

Pickled, as purchased, . . 

VEAL. 

Breast : 

Edible portion, 

As purchased, 

Chuck : 

Edible portion, 

As purchased, 

Flank, as purchased, 

Leg, whole : 

Edible portion, 

As purchased, 

Leg, cutlets : 

Edible portion, 

As purchased, 

Loin : 

Edible portion, 

As purchased, 

Neck : 

Edible portion, 

As purchased, 

Rib: 

Edible portion, 

As purchased, 

Rump : 

Edible portion, 

As purchased, 

Shank, fore : 

Edible portion, 

As purchased, 

Shank, hind : 

Edible portion, 

As purchased, 

Fore auarter : 

Edible portion, 

As purchased, 



Per cent. 
18.3 



21.4 



12. 1 



14-5 
£0 



20.6 
18.9 

15.6 

4.0 
17-3 
3i-5 
26.9 
30.2 
40.4 
627 
24-5 



Cal- 
ories. 

1205 
980 
665 



1390 
1090 

1660 
1465 

2015 
1720 

1270 
"95 



845 



1380 

1450 
1 100 



740 

630 
5io 
805 

730 
620 

805 

775 

800 
660 

655 
440 

635 
470 

1055 
735 

590 
35o 

565 
210 



700 
525 



COMPOSITION OF MEATS. 



103 



Table Showing the Chemical Composition and Fuel Value per Pound of 
Meats. — ( Continued. ) 



Kind and Cut of Meat. 



Refuse. 


Water. 




Nutrients. 




Water- 
free 
sub- 
stance. 


Pro- 
tein. 


Fat. 


Carbo- 
hy- 
drates. 


Ash. 


Percent. 
20.7 


Per cent. 
70.9 
56.2 


Per 
cent. 
29.1 
23.1 


Per 
cent. 
19.8 
15-7 


Per 

cent. 

8-3 

6.6 


Per 
cent. 


Per 

cent. 

1.0 

0.8 


22"6 


71.3 
55-2 
73-1 


28.7 
22.2 
26.9 


19.6 
15- 1 
20.4 


8.1 
6.3 
5-3 




1.0 
0.8 
1.2 


19. 1 


56.2 
45-5 


43-8 
35-4 


19.2 
15-5 


23.6 
19.1 




1.0 

0.8 


17.4 


639 
52.9 


36.1 
29.7 


18.5 
152 


13.6 




I.I 

0.9 


14.8 


53-1 
45-3 


46.9 
39-9 


17.6 
15-0 


28.3 
24.1 




1.0 

0.8 


17.7 


56.7 
46.7 


43-3 
35-6 


17.5 
14.4 


24.8 
20.4 




1.0 

0.8 


20.3 


51.8 
41.3 


48.2 
38.4 


17-5 
14.0 


29.7 
23.6 




1.0 

0.8 


21.3 


50.9 
39-9 
45-8 


49.1 
38.8 
54-2 


14.6 
11.5 
14.8 


H- 6 

26.7 

38.7 




0.9 
0.6 
0.7 


18.0 


62.8 
5i-4 


37-2 
30.6 


18.2 
14.9 


18.0 
14.9 




1.0 
0.8 


15-3 


50.1 
42.2 


49-9 
42.5 


15-9 
132 


33-2 
28.6 




0.8 

0.7 


28.4 


5 H 
41.6 


41.8 
30.0 


16.3 
11.7 


24-5 
17.6 




1.0 

0.7 


21.7 


61.9 

48.5 


38.1 
29.8 


17-3 
13-5 


19.9 
156 




0.9 

0.7 


21. 1 


51-7 
40.6 


48.3 
38.3 


150 
11.9 


32.4 
25-7 




0.9 
0.7 


16.7 


54-8 
45-6 


45-2 
37-7 


16.2 
13-5 


28.2 
23-5 




0.8 
0.7 


19.2 


53-1 
42.9 


46.9 
37-9 


15-4 
12.5 


307 
24.7 




0.7 
0.7 


18" 1 


5i.« 

41.8 


48.9 
40.1 


16.9 
13.8 


3ii 
25-5 




°-2 

0.8 


n'x.z 


59-0 
17.0 


41.0 
EX.8 


17.8 
5-i 


22.2 
6.4 




1.0 

0.3 



Fuel 
Value 

per 
Pound. 



VEAL. 

Hind quarter : 

Edible portion, . 

As purchased, , 
Side: 

Edible portion, , 

As purchased, . 
Liver, as purchased, 

LAMB. 

Breast : 

Edible portion, , 

As purchased, . 
Leg, hind : 

Edible portion, . 

As purchased, . 
Loin: 

Edible portion, . 

As purchased, . 
Neck: 

Edible portion, . 

As purchased, . 
Shoulder : 

Edible portion, . 

As purchased, . 

MUTTON. 

Chuck : 

Edible portion, . 

As purchased, . 
Flank, as purchased 
Leg, hind : 

Edible portion, . 

As purchased, . 
Loin: 

Edible portion, . 

As purchased, 
Neck: 

Edible portion, . 

As purchased, . 
Shoulder : 

Edible portion, . 

As purchased, 
Fore quarter : 

Edible portion, . 

As purchased, . 
Hind quarter : 

Edible portion, . 

As purchased, . 
Side, without tallow 

Edible portion, . 

As purchased, . 

PORK. 

Chuck and shoulder 

Edible portion, . 

As purchased, 
Flank : 

Edible portion, . 

As purchased, 1 . 



Cal- 
ories. 
720 
57o 

705 
545 
605 



1355 
1095 

1040 
855 

1520 
1295 

1375 
1130 

1580 
1255 



1690 
1340 
1910 

1100 
905 

1695 
1450 

960 

1 160 
910 

1645 
1305 

1490 
1245 

1580 
1275 



1630 
1335 

1265 
365 



VI— 7 



1 Refuse includes fat trimmings. 



io4 



COMPOSITION OF MEATS. 



Table Showing the Chemical Composition and Fuel Value per Pound of 

Meats. — ( Continued. ) 



Kind and Cut of Meat. 



pork. 
Loin : 

Edible portion, 

As purchased, 

Leg, hind : 

Edible portion, 

As purchased, 

Ham, smoked : 

Edible portion, 

As purchased, 

Ham. boneless, as purchased, 
Shoulder, fresh : 

Edible portion, 

As purchased, 

Shoulder, smoked : 

Edible portion, 

As purchased, 

Salt, clear fat, as purchased, . 
Salt, lean ends : 

Edible portion, 

As purchased, 

Bacon, smoked : 

Edible portion, 

As purchased, 

Feet: 

Edible portion, 

As purchased, 

Ham, deviled, canned, as pur- 
chased, 

Side: 

Edible portion, 

As purchased, 

SAUSAGE. 

Bologna : 

Edible portion, 

As purchased/ 

Frankfort, as purchased, . . . 

Pork, as purchased, 

Tongue, as purchased, . . . . 

SOUPS, CANNED. 

Bouillon, as purchased, . . . . 
Chicken, as purchased, .... 
Consomme, as purchased, . . 
Mock turtle, as purchased, . . 
Ox tail, as purchased, .... 
Tomato, as purchased, .... 



POULTRY 

Chicken : 

Edible portion, 

As purchased, 
Fowl: 

Edible portion, 

As purchased, 
Goose : 

Edible portion, 

As purchased, 
Turkey : 

Edible portion, 

As purchased, 

Chicken, canned, as purchased 
Quail, canned, as purchased, 
Turkey, canned, as purchased 



Refuse. 


Water. 




Nutrients. 




Water- 
free 
sub- 
stance. 


Pro- 
tein. 


Fat. 


Carbo- 

hy- 
drates. 


Ash. 


Per cent. 
i's's 


Per cent. 
52.0 
43-8 


Per 
cent. 
48.0 
40.4 


Per 
cent. 
16.8 
14. 1 


Per 
cent. 
30.3 
25.6 


Per 
cent. 


Per 

cent. 

0.9 

0.7 


42.4 


62.8 
35-7 


37-2 
21.9 


18.5 
10.7 


17.7 
10.6 




1.0 
0.6 


14.4 


40.7 
34-9 
50.1 


59-3 
50.7 
49-9 


15-5 
13-3 
154 


39' 1 

334 
28.5 




4-7 
4.0 
6.0 


46.6 


57-5 
304 


42.5 
23.0 


15-6 
8-3 


26.1 
14-3 




0.8 
0.4 


154 


46.8 

39-8 
7-3 


53-2 
44.8 
92.7 


15.5 

1.8 


33-3 
28.1 
87.2 




44 
3-6 
3-7 


11. 2 


19.9 

17.6 


80.1 
71.2 


I' 3 

6.5 


67.1 
59-6 




5-7 
5-i 


£0 


18.2 
16.8 


81.8 
75-2 


10.0 

9.2 


67.2 
61.8 




4.6 
4.2 


35-5 


68.2 
44.6 


31.8 
19.9 


16. 1 

10.0 


14.8 
9-3 




0.6 




45-3 


54-7 


18.9 


32.9 




2.9 


11.2 


29.4 
26.1 


70.6 
62.7 


8.5 

7-5 


61.7 
54-8 




0.4 
0.4 


3-3 


59-5 
55-2 
55-5 
38.7 
46.4 


40.5 
4i-5 
44-5 
61.3 
53-6 


18.6 
18.0 
21.7 
12.8 
17.3 


18.2 
19.7 
18.8 
454 
33-i 


O.I 

0.4 
0.8 


3-6 
3-8 
3-6 
2-3 

3-2 




96-5 
93-8 
96.0 
89.8 
88.8 
90.0 


3-5 
6.2 
4.0 
10.2 
11. 2 
10.0 


2.0 
3-6 
2-5 

5-2 

4.0 
1.8 


0.1 

O.I 

0.9 
1-3 
I.i 


0.2 

i-5 
0.4 
2.8 

5.6 


1.2 
1.0 
I.I 
1-3 
1.6 

i-5 


34-8 


74.2 
48.5 


25.8 
16.7 


22.8 
14.8 


1.8 
I.i 




1.2 
0.8 


30.0 


66.3 
46.5 


33-7 
23-5 


18.2 
12.5 


14.4 
10.2 




2.1 
0.8 


22.2 


42.3 
33-i 


57-7 
44-7 


13.0 
10.3 


43-9 
33-8 




0.8 
0.6 


22.7 


55-5 
42.4 
46.9 
66.9 
474 


44-5 
34-9 
53-1 
33-1 
52.6 


20.6 
15-7 
20.5 
21.8 
20.7 


22.9 
18.4 
30.0 
8.0 
29.2 


i-7 


1.0 

0.8 
2.6 
1.6 
2.7 



Fuel 

Value 

PER 

Pound. 



Calo- 
ries. 

1590 
1340 

1090 
645 

1940 

1655 
1490 

1390 
760 

1695 
1430 
3715 

2965 
2635 

3020 
2780 

925 

580 

1740 

2760 
2455 



n * 5 

1 165 

1205 
2155 
1720 



45 
100 

xll 

210 

185 



500 
325 

945 
665 

2095 
1620 

1350 
1070 

1645 
775 
1400 



1 Refuse, case. 



COMPOSITION OF FISH. 



I05 



COMPOSITION OF FISH, MOLLUSKS, CRUSTACEANS, ETC. 



Kind of Food Material. 



FRESH FISH. 

Alewife, whole, 

Bass, large-mouthed black, 

dressed, 

Bass, large-mouthed black, 

whole, 

Bass, small-mouthed black, 

dressed, 

Bass, small-mouthed black, 

whole, 

Bass, sea, dressed, 

Bass, sea, whole, 

Bass, striped, dressed, . . . 

Blackfish, dressed, 

Bluefish, dressed, 

Butterfish, dressed, 

Butterfish, whole, 

Carp ( European analysis) , . 

Cod, dressed, 

Cod, steaks, 

Cusk, dressed, 

Eel, salt-water, dressed, . . 
Flounder, common, dressed, 
Flounder, winter, dressed, . 

Hake, dressed, 

Haddock, dressed, 

Halibut, dressed, 

Herring, whole, 

Mackerel, dressed, 

Mackerel, Spanish, dressed, 
Mackerel, Spanish, whole, . 

Mullet, dressed, 

Mullet, whole, 

Perch, white, dressed, . . . 
Perch, white, whole, .... 
Perch, yellow, dressed, . . . 
Pickerel, dressed, ..... 
Pickerel, whole, ...... 

Pike, dressed 

Pike, whole, 

Pollock, dressed, 

Pompano, dressed, 

Porgy, dressed, 

Porgy, whole, 

Red grouper, dressed, . . . 
Red snapper, dressed, . . . 
Salmon, California (sections), 
Salmon, Maine, dressed, . . 

Shad, dressed, 

Shad, whole, 

Shad, roe, 

Smelt, whole, 

Sturgeon, dressed, 

Tomcod, dressed, 

Tomcod, whole, 

Trout, brook, dressed, . . . 
Trout, brook, whole, .... 
Trout, lake, dressed, .... 

Turbot, dressed, 

Turbot, whole, 

Weakfish, dressed, 

Weakfish, whole, 

Whitefish, dressed, 

Whitefish, whole, 

General average of fresh fish 

as sold, 



w -o 

W W (- 

b. O - 



Per 
cent. 

49-5 

46.7 

56.0 

46.4 

53-6 
46.8 
56.1 
51-2 
55-7 
48.6 
34-6 
42.8 
37-1 
29.9 
9.2 

40.3 
20.2 
57.o 
56.2 
52.5 
51.0 
17.7 
46.0 
40.7 
24.4 
34-6 
49.0 
57.9 
54-6 
62.5 
35-1 
35-9 
47-1 
30.5 
42.7 
28.5 
45-5 
53-7 
60.0 
55-9 
48.9 
5-2 
23.8 
43-9 
50.1 

41.9 
14.4 
51-4 
59-9 
37-9 
48.1 
35-2 
39-5 
47-7 
41.7 

43-6 
53-5 

42.0 



■J 




Z 

s 




Sg 




22 


< 


< 




< 


2 5 


a 


in 


* 


ft 

Oh 


(Xh 


< * 




Per 


Per 


Per 


Per 


Per 


Per 


Per 


cent. 


cent. 


cent. 


cent. 


cent. 


cent. 


cent. 




37-5 


9-7 


2.5 




0.8 


130 




41.9 


10.3 


0.5 




0.6 


11.4 




34-6 


8-5 


0.4 




0.5 


94 




40.1 


"•5 


i-3 




0.7 


13-5 




34-7 


10.0 


1.1 




0.6 


1 1.7 




42.2 


10. 1 


0.2 




0.7 


11. 




34-« 


8-3 


0.2 




0.6 


9.1 




37-4 


8.7 


2.2 




0.5 


11.4 




35-0 


8-3 


0.5 




0.5 


9-3 




40.3 


9.8 


0.6 




0.7 


11. 1 




45-» 


11.7 


7.2 




0.7 


19.6 




40.1 


10.2 


6.3 




0.6 


17.1 




48.4 


12.9 


0.7 




0.9 


14-5 




58.5 


10.6 


0.2 




0.8 


11.6 




72.4 


16.9 


0-5 




1.0 


18.4 




49.0 


10. 1 


0.1 




0.5 


10.7 




57-2 


14.6 


7.2 




0.8 


22.6 




35.8 


6-3 


o.3 




0.6 


7-2 




37-o 


6.1 


0.2 




o-5 


6.8 




39-5 


7.2 


0.3 




0.5 


8.0 




40.0 


8.2 


0.2 




0.6 


9.0 




61.9 


15-1 


44 




0.9 


20.4 




37-3 


10.0 


5-9 




0.8 


16.7 




43-7 


11.4 


3-5 




0.7 


15.6 




51-4 


15.8 


7.2 




1.2 


24.2 




44-5 


13.7 


6.2 




1.0 


20.9 




38.2 


15 


2.4 




0.6 


12.8 




31-5 


2.0 




0-5 


10.6 




34-4 


8.7 


1.8 




0.5 


11.0 




28.4 


7.2 


1-5 




0.4 


9-1 




50-7 


12.6 


0.7 




0.9 


14.2 




5i-i 


"•2 


0.2 




0.9 


13.0 




42.2 


9.8 


0.2 




0.7 


10.7 




55-4 


13.0 


0.4 




0.7 


14.1 




45-7 


10.7 


0.3 




0.6 


11.6 




54-3 


15-5 


0.6 




1.1 


17.2 




39-5 


10.2 


4-3 




0.5 


15-0 




34-6 


8.6 


2.4 




0.7 


11.7 




29.9 


74 


2.1 




0.6 


IO.I 




35-0 


8.4 


0.2 




0.5 


9-i 




40-3 


9.6 


0.6 




0.6 


10.8 




60.3 


16.5 


17.0 




1.0 


34-5 




51.2 


14.6 


9-5 




°o% 


25.0 




39-6 


10.3 


54 




16.5 




35-2 


9.2 


4.8 




0.7 


14.7 




71.2 


23-4 


3-8 




1.6 


28.8 




46.1 


10.0 


Z.6 




1.0 


12.0 




67.4 


154 


1.6 




1.2 


18.2 




39-6 


8.2 


0-3 




0.5 


9.0 




32.7 


6.8 


0.2 




O.4 


74 




48.4 


11.7 


1-3 




O.7 


13-7 




40.4 


9-8 


1.1 




0.6 


II-5 




45-o 


12.4 


6.6 




0.8 


19.8 




43-1 


7-9 


8.7 




0.8 


17.4 




37-3 


6.8 


7-5 




0.7 


15.0 




46.1 


10.2 


1-3 




0.7 


12.2 




38.0 


8.4 


1.1 




0.6 


IO.I 




39-4 


12.5 


3-6 




0.9 


17.0 




32-5 


10.3 


30 




0.7 


14.0 




44.0 


10.5 


2-5 




1.0 


14.0 



Calories. 

285 

215 

175 

270 

230 

160 
255 
175 
205 
520 

455 
270 
205 
335 
190 

575 
130 
120 

145 
160 
465 
435 
360 
595 
515 
285 
235 
235 

265 
230 

3£ 

260 
210 

315 

370 

260 

225 

165 

205 
1025 

675 

420 
375 
595 
230 

135 
275 
230 
5io 
515 
440 

245 
200 
385 
320 

300 



io6 



COMPOSITION OF FISH. 



Composition of Fish, Mollusks, Crustaceans, etc. — {Continued.) 



Kind of Food Material. 



PRESERVED FISH. 

Mackerel, *' No. i," salted, . 

Cod, salted and dried, . . . 

Cod, "boneless codfish," 
salted and dried, 

Caviare, 

Herring, salted, smoked, 
and dried, 

Haddock, " Finnan -had- 
dock," salted, smoked, 
and dried, 

Halibut, salted, smoked, and 
dried, 

Sardines, canned 

Salmon, canned, 

Mackerel, canned, 

Mackerel, salt, canned, . . . 

Tunny (horse mackerel), 
canned, 

Haddock, smoked, canned, 

MOLLUSKS. 

Oysters, solids, 

Oysters, in shell, 

Oysters, canned, 

Scallops 

Long clams, in shell, .... 
Long clams, canned, .... 
Round clams, removed from 

shell 

Round clams, in shell, . . . 
Round clams, canned, . . . 

Mussels, 

General average of mollusks 

(exclusive of canned), . . 

CRUSTACEANS. 

Lobster, in shell, . 
Lobster, canned, . 
Crawfish, in shell, 
Crab, in shell, . . 
Crab, canned, . . 
Shrimp, canned, . 
General average of crustace- 
ans (exclusive of canned), 

TERRAPIN, TURTLE, ETC. 

Terrapin, in shell, 

Green turtle, in shell, .... 

Average of turtle and terra- 
pin, 

Frogs' legs, 

General average of fish, mol- 
lusks, crustaceans, etc., . . 



^ 












w -u 

W g H 

no" 

CO 


H 

►J 

< 
CO 


w 

h 
< 


w 

H 

O 
BS 


V) 

H 

< 




Per 


Per 


Per 


Per 


Per 


Per 


cent. 


cent. 


cent. 


cent. 


cent. 


cent. 


33-3 


7-i 


28.1 


14.7 


i5-i 




24.9 


17.2 


40.3 


16.0 


0.4 






21.5 


54-4 


22.1 


0.3 








38,1 


30.0 


19.7 


7.6 


444 


6-5 


19.2 


20.2 


8.8 




32.2 


1.4 


49.2 


16.1 


0.1 




6.9 


12.1 


46.0 


19.1 


14.0 




5-o 




53-6 


24.0 


12. 1 




3-9 


1.0 


59-3 

68.2 


19-3 


15-3 






1.9 


SI 


8.7 




19.7 


8-3 


34-8 


213 








72.7 


Hi 


4.1 






5-6 


68.7 


2-3 








88.3 


6.1 


1.4 


3-3 


82.3 




15.4 


1.1 


0.2 


0.6 






85.3 


7-4 


2.1 


3-9 






80.3 


14.7 


0.2 


34 


43-6 




48.4 


4.8 


0.6 


1.1 






84-5 


9.0 


1-3 


2.9 






80.8 


10.6 


i.l 


5-2 


68.3 




27.3 


2.1 


0.1 


i-3 






83.0 


10.4 


0.8 


3-o 


49-3 




42.7 


4.4 


0-5 


2.1 


60.2 




34-o 


3-2 


0.4 


1-3 


62.1 




3i-i 


5-5 


0.7 








77.8 


18.1 


1.1 


0.6 


87.7 




10.0 


2.0 


0.1 


0.1 


55-8 




34-1 


7-3 


0.9 


0.5 






80.0 


15.8 


i-5 


0.8 






70.8 


25-4 


1.0 


0.2 


737 




20.9 


4-3 


0.4 


0.2 


79.0 




15.6 


4-5 


0.7 




76.0 




19. 1 


4-5 


0.1 




77.5 




17.4 


4.2 


0.7 




32.0 


... 


57-0 


10.2 


0.1 




44.0 


... 


42.5 


10.0 


2.5 


O.I 



Per 
cent. 

1-7 
1.2 

i-7 
14.6 

0.9 



0.9 
0.4 

1-3 
1.4 

1-5 
23 

2.3 
0.9 
2.8 
1.0 

0.9 



0.6 
2.4 
0.1 
1.4 

1-9 
2.6 

0.5 



0.2 
03 



0.2 
0.7 



0.9 




Per 

cent. 



3i-5 
17.6 



24.1 
61.9 



29.9 



17.2 

35-o 
41.4 
35-8 
29.9 
37-2 

27.3 
25-7 



11.7 
23 

14.7 

19.7 
8.0 

15.5 

19.2 
44 

17.0 
8.0 

5-8 



6.8 
22.2 

2-3 
10. 1 
20.0 
29.2 

54 



54 
4-9 



5-1 
11.0 



13-5 



PD 



Calories. 
910 
315 

425 
1530 

45 



305 

945 

955 
1005 

735 
1 155 

575 
505 



235 
40 
300 
345 
135 
275 

340 

285 
140 



130 
395 

i 5 
185 
370 
520 



"5 
90 



105 
210 



295 



Including salt. 



CHAPTER VIII 

VEGETABLE FOODS 

Digestibility. Sugars. Cereals. Roots and Tubers. Peas and 
Beans. Green Vegetables. Fruits. Nuts. Fungi. Spices and 
Condiments. 

Vegetable foods differ from animal foods in the large amount 
of sugar and starch and the relatively small amount of protein 
and fat that they contain. They also contain a large quantity 
of water. A cabbage is richer in water than is milk. The 
great water-content of vegetables makes them bulky foods, 
and their small nitrogen value necessitates the eating of a large 
quantity in order to supply the protein that is required. As 
vegetable albumin is so much less readily absorbed from the 
intestines than is animal albumin, the total quantity of vege- 
table matter that must be eaten to supply all the ingredients 
needed for the maintenance of life is increased still more. 
It is estimated that of dry lentils, which, for a vegetable food, 
contain a large amount of nitrogenous matter, 2000 grams will 
be needed to supply as much protein as is necessary for a day's 
rations for a man, or as much as will be supplied by 600 grams 
of cooked meat. 

Digestibility 

The sugars and starches of vegetable foods are very perfectly 
digested and absorbed. Most vegetable oils and fats are rapidly 
absorbed. The proteins are not. Cellulose, which, except 
when very young, is indigestible, seems to interfere with the 
digestion and absorption of the proteins. The protein of 
vegetables is contained in cells as starch is; but when cooked, 
starch swells and bursts the envelop of cellulose, while protein, 
like other albumins when heated, shrinks and remains inside 

107 



108 VEGETABLE FOODS. 

its almost indigestible shell. Probably the quickening of 
intestinal movements that a vegetable diet produces also plays 
a part in preventing its perfect absorption. Forty per cent, of 
the protein of beans when they have been simply soaked and 
boiled until they are soft is lost in the feces. If they are ground 
to a fine powder and the cellulose shell about the protein is thus 
broken, it is almost as well digested and absorbed as is animal 
albumin. 

Unquestionably a mixed diet provides the necessary constit- 
uents in the most digestible and absorbable form. The ratio 
that should exist between animal and vegetable food is vari- 
ously estimated. It is probable that one part of raw animal food 
to three parts of raw vegetable food is as nearly accurate a ratio 
as can be established. In a large number of dietaries collected 
in the United States 45 per cent, of the food was of animal ori- 
gin. This is a high percentage, and especially so for those who 
lead a sedentary life. However, for the latter class a large 
amount of vegetable food proves indigestible because its bulk is 
a tax upon the muscular power of the alimentary canal, and 
because, when not digested rapidly, it is especially liable to 
fermentation, forming acids that often provoke intestinal 
inflammation, acute or chronic. A man doing hard muscular 
work needs an abundance of carbohydrate to furnish him with 
strength. His work maintains good muscular activity of his 
alimentary canal. The free action of skin and lungs also pro- 
duced by it enables him to dispose of the excess of water that 
a bulky vegetable diet makes unavoidable. 

If such foods are eaten hastily by those who are weak, dis- 
tention of the stomach and intestines is likely to be produced, 
and ultimately, because of slow digestion and fermentation of 
food, inflammation of these structures. Only those vegetables 
that are most digestible and least likely to ferment should be 
eaten under these circumstances, and then in small or moderate 
portions. 

The sugar of vegetable foods is in their juices. It is the circu- 
lating form of carbohydrate in plants. Starch is the form in 
which it is stored. Sugar is soluble, starch is not. In cold 
water starch undergoes no change, but in hot water it swells, 
breaks its envelop of cellulose, and is washed out. Cooking is, 



SUGARS. IO9 

therefore, essential to make food containing starch capable of 
digestion. Dry heat can convert starch into dextrin, which is 
soluble. 

Cellulose is a carbohydrate that is different from starch, being 
both insoluble and indigestible except when it is very young. 
It is, however, especially subject to attack by micro-organisms 
that generate marsh-gas from it. As sustenance for the human 
body it is of inappreciable importance. It does stimulate the 
muscular activity of the intestine by its bulkiness, and foods 
rich in it, such as brown bread, green vegetables, and fruits, are 
eaten to correct constipation. 

Vegetable proteins are mostly globulins. Vegetable as com- 
pared with animal food is poor in nucleo-albumins. Like other 
proteins, those derived from vegetables coagulate with heat. 

Chemical constituents resembling the extractives of meat are 
also found in vegetables. The fats or oils are for the most part 
digestible. Vegetables contain most of the salts needed for the 
maintenance of life, but they are comparatively rich in potas- 
sium salts and poor in sodium. 
Sugars 

Sugar is the form of carbohydrate that needs least modifica- 
tion by digestion before it is absorbed. Dextrose needs more. 
The changes that must be effected in cane-sugar and other 
sugars have already been discussed in the chapter devoted to 
Digestion and Assimilation. 

Cane-sugar, which in commerce is chiefly derived from sugar- 
cane and sugar beet, is the form most used. Maple -sugar is 
cane-sugar, but contains certain ethereal substances that give 
it its characteristic taste. Maltose, or malt-sugar, lactose, or 
milk-sugar, glucose, or grape-sugar, levulose, or fruit-sugar, and 
invertose, or invert sugar, are other forms met with in foods 
more or less frequently. 

Molasses and syrup are crude forms of cane-sugar. Honey 
consists of approximately 20 per cent, of water, 35 per cent, of 
grape-sugar, 39 per cent, of fruit-sugar, and 5 per cent, of sub- 
stances other than sugar. It is obtained by bees from flowers 
and stored in cells of wax. 

Since both sugar and starch must be transformed into dex- 
trose before they are utilizable, they may be said to be identical 



IIO VEGETABLE FOODS, 

as nourishment. Sugar is agreeable to the taste, which is 
important, as it creates an appetite or liking for food to which it 
is added. Starch is almost tasteless. 

Sugar is a concentrated form of nourishment that especially 
gives strength to muscles and helps to produce fat. It has long 
been known to be a strength producer, but its value was not 
fully appreciated until demonstrated by Morro with the aid of 
the myograph, an instrument that records the amount of work 
done by a muscle or group of muscles. He found that sugar in 
food in not too great quantities and not too concentrated lessens 
or delays fatigue and increases working power. Vaughan Har- 
ley and others have confirmed these results by repeated experi- 
ments. When muscles are wearied by hard work, they can be 
revived by a meal of sugar with great rapidity and to a notice- 
able degree. The effect of sugar on muscular work is demon- 
strated a half hour after meals, but is greatest two hours after. 
Tests of its value confirming these laboratory experiments of 
Morro and Harley have been made upon soldiers, athletes, and 
others who were submitted to hard muscular work. 

Sugar is more quickly utilizable by the body than is starch. 
It is adapted for use in infancy when starch cannot be digested 
and in some dyspeptic states. It produces fat as well as 
strength, and may be prescribed or forbidden as one desires to 
put on fat or lose it. If used in too large quantities it will cause 
indigestion. Harley took nearly a pound daily without injury 
except to the stomach. Three or four ounces can be taken 
daily by an adult without harm. If too much is taken, it will 
not be held by the liver but will enter the blood in abnormally 
large amounts and be rapidly excreted by the kidneys. This is 
called a dietetic or alimentary glycosuria and is temporary. If 
such glycosuria is persistently or frequently provoked, it will 
cause pathologic conditions. All forms of sugar do not produce 
glycosuria with equal readiness. Hutchison found that it was 
provoked by the following kinds, with the amounts given in this 
table : 

Lactose 120 grams 

Cane-sugar 150-200 grams 

Levulose 200 grams 

Dextrose 200-250 grams 



CEREALS. Ill 

The readiness with which glycosuria is provoked varies also in 
different persons. 

Large quantities of sugar or of sweetened food are likely to 
ferment in the stomach and intestines, producing alcohol and 
acids that may excite inflammation in those organs. Aitchison 
Robertson found that different sugars vary in their susceptibil- 
ity to fermentation. 

The following undergo lactic acid fermentation with relative 
ease in the order in which they are named: Levulose, most fer- 
mentable, lactose, dextrose, invert sugar, cane-sugar, maltose. 
The following list shows the relative ease with which butyric 
acid fermentation can be provoked: Levulose, most ferment- 
able, maltose, dextrose, invert sugar, cane-sugar, lactose. The 
following shows the relative ease with which alcoholic fermenta- 
tion is produced: Maltose, invert sugar, cane-sugar, dextrose, 
levulose, lactose. It is noticeable that lactose is least likely to 
undergo any of these forms of fermentation, which makes it 
especially useful when we wish to avert them. Dyspeptics 
should use sugar sparingly. Many of them cannot use it even in 
tea and coffee without discomfort. 

Sugar should be taken well diluted. Nature furnishes it in 
milk and most fruits in very small proportion — rarely more than 
from 4 to 6 per cent. Experience teaches us that it is best 
borne by stomach and bowels when taken in this way. Candies 
and food upon which a syrup is used, and compotes that are 
very sweet, are often indigestible because they contain sugar 
in concentration. There is no evidence substantiating the 
popular notion that sugar causes the teeth to decay. Un- 
doubtedly if starch is allowed to cling long to the teeth or to 
accumulate in the interstices between them it will ferment and 
produce acids that may be harmful. If the mouth and teeth 
are kept clean, it will not produce these results. 

CEREALS 

Cereals are the grains that are used for food. They contain 
relatively little cellulose, much starch, and variable amounts 
of oil, gluten, and mineral matter; the exact chemical composi- 
tion varying in different species. Cereals are rarely eaten until 



112 VEGETABLE FOODS. 

they have been crushed or ground to a powder. The outer 
layers form bran, which consists chiefly of cellulose and is 
extremely difficult to convert into flour. By modern milling 
processes the germ as well as the bran is removed from the flour. 
The former contains a relatively large amount of nitrogenous 
matter and oil. It easily becomes rancid, and flour containing 
it may spoil. The proteins can convert some of the starch of 
flour into dextrin and sugar, which will render bread made from 
it darker in color than is agreeable. The following table, from 
Hutchison, shows the composition of the different parts of the 
grain : 

Bran, Endo- Germ, 1.5 Whole 

13.5 Per sperm, 85 Per Cent. Grain, 100 

Cent. Per Cent. Per Cent. 

Water I2 -5 13 .0 I2 -5 I 4-5 

Nitrogenous matter 16.4 10.5 35-7 11.0 

Fats 3.5 0.8 13. 1 1. a 

Starch and sugar 43-6 74-3 31.2 69.0 

Cellulose 18.0 0.7 1.8 2.6 

Mineral matter 6.0 0.7 5.7 1.7 

The best grades of wheat flour are to-day made from the 
endosperm. The compositoin of flour from various cereals is 
given in the subjoined table, taken from a report of the United 
States Department of Agriculture. 

Carbo- Mineral 

Water Protein Fat hydrate Cellulose MAtter 

Wheat meal ... . 12.0 12.9 1.9 70.3 1.6 1.2 

Fine wheat 

flour 13.0 9.5 0.8 75.3 0.7 0.7 

Oatmeal 7.2 14.2 7.3 65.9 3.5 1.9 

Rolled oats 7.2 15. 4 7.2 64.8 3.5 1.9 

Barely meal ... . 11. 9 10. o 2.2 71. 5 1.8 2.6 
Coarse rye 

flour 11. 4 15.3 2.1 66.7 2.3 2.2 

Finest rye 

flour 11. 2 6.7 0.9 80.0 0.8 0.4 

Cornmeal 11.4 8.5 4.6 72.8 1.4 1.3 

Cornmeal, fine. 12.5 6.8 1.3 78.0 0.8 0.6 
Buckwheat 

flour _ 14.0 7.1 1.2 75-9 0.6 0.2 

Rizine (flaked 

rice) 11. 7 7.9 0.5 79.5 0.4 

To utilize flour as food it must be cooked. The simplest way 



PROTEID. 113 

is to boil it. However, only the coarser meals are cooked in 
this way. Usually they are eaten with cream or milk and 
sugar. Flour can be mixed with water, molded into definite 
form, and baked. It is in this way that ship biscuits are made. 
Primitive races cook flour only in this way. The product is 
hard, difficult to break and to disintegrate with the teeth, and 
as much of it is likely to be swallowed before it is perfectly 
masticated, it is not easily digested. 

Bread is the chief food-product of flour. It is made by mix- 
ing flour with water and adding a little salt and sometimes 
sugar. Yeast is added to the mixture, which is then set aside 
in a warm place. The yeast-cells grow and convert some of the 
starch into sugar and then into alcohol and carbonic acid gas. 
This gas fills the dough with bubbles, which make it light and 
spongy. The fermentation ceases when the bread is baked. 
The yeast is killed, and most of the alcohol and gas is driven 
off. In this process a small amount of nutriment is also lost. 
One and three-tenths per cent, of the proteins, 71.2 per cent, 
of the fats, and 3.2 per cent, of carbohydrate are lost, or about 
5 per cent, of the calories that might be generated from the 
flour. To avoid this loss two processes are used. In the first, 
which is rarely resorted to, the dough is 'aerated' by gas pro- 
duced outside and forced into it. In the second, the more 
common process, baking-powders are used. They consist of 
mixtures of powdered chemicals which, when wet or mixed 
with moist dough, liberate carbonic acid gas. 

Stale bread is much more digestible than hot or fresh bread, 
for the latter, when masticated, is made into a tenacious, 
dough-like mass. The former crumbles into finer particles, 
which are attacked by digestive fluids with comparative read- 
iness. Toast is bread that is cooked in slices until it is brown 
and brittle. Toasting, if it is properly done, makes bread 
more digestible. Often only the surface of slices of bread is 
toasted and the interior is left soft. Such toasting does not 
increase the digestibility of bread. Zwieback is well-toasted 
bread. Pulled bread is the heart of a loaf that has been baked 
until it has become thoroughly brittle. The readiness with 
which cereal foods are digested depends greatly upon the ease 
with which they are disintegrated, and the fineness of their 
8 



114 VEGETABLE FOODS. 

division during mastication and during their stay in the 
stomach. 

An average slice of bread remains in the stomach about two 
and one-half hours. There is little difference in the behavior 
of whole wheat and fine flour bread in the stomach, but a con- 
siderable difference in their absorbability from the intestines. 
The following table, from Hutchinson, shows the relative 
amount of their constituents in the stools : 

White Bread Whole Wheat Bread 

Total solids 4.5 per cent. 14 per cent. 

Proteins 20.0 per cent. 20 to 30 per cent. 

Ash 25.0 per cent. 5 1 per cent. 

Carbohydrates, 3.0 per cent. 6 per cent. 

The excess of cellulose in whole wheat bread interferes with 
the absorbability of the latter. The larger percentage of fat 
and protein makes it more likely to ferment in the intestines 
and provokes soft and numerous stools. 

Bread is considered one of the most nutritious forms of food, 
but owing to the relatively small amount of protein it contains, 
it is not a perfect food. It should be looked upon as an impor- 
tant supplement to meat and fat. Meat powder has been added 
to bread to increase its nutritive properties. Milk, skim milk, 
and cheese have been used similarly. 

Oats are chiefly used as porridge. Unless other flour is 
mixed with oatmeal, good bread cannot be made from it. It 
is particularly difficult to separate the husks of oats from the 
kernel. Oatmeal is especially rich in fat. In certain persons 
it has the peculiarity of provoking skin eruptions. Cornmeal 
(maize) contains less protein than most others, but relatively 
a large amount of fat. It is eaten as mush, as bread, and as 
johnny-cakes. Hominy, cerealine, and samp are special prep- 
arations of corn that are particularly adapted for making 
puddings and mush. Barley meal contains little gluten, and 
therefore good bread can be made from it only when it is 
mixed with other flour. Bread made in this way is agreeable 
and nutritious. Barley-water, which is much used as a diluent 
of milk for children and in the sick-room, contains very little 
nutriment, for 99 per cent, of it is water. About 1/3 of 1 per 



ROOTS AND TUBERS. 115 

cent, is starch, its next largest ingredient. Next to wheat, rye 
is the best bread-making flour. Rye bread is not quite so 
nutritious as that made from wheat. When its flour is fine it is 
quite as digestible, but when coarse, as is often the case, it is 
wasteful, for much of it remains in the ieces undigested. Rice 
contains a small amount of protein and almost no fat. Two 
and one-half ounces of boiled rice are disposed of by the stomach 
in three and one-half hours. It is absorbed from the intestines 
very completely. Its starch is practically all utilized. The 
amount of protein it contains is so small that it leaves almost 
no residue in the bowel, although 20 per cent, of it is not ab- 
sorbed. Rice contains no cellulose. 

Granose is a partially cooked preparation made of whole 
wheat in the form of flakes. It is easily digested. Shredded 
wheat is a preparation of whole wheat in the form of flakes 
having the consistence of a biscuit. It is also easy to digest. 
Imperial granum is one of a large number of preparations pre- 
scribed for invalids and children. It contains more than 75 
per cent, of starch. Like most of its class, it is not adapted for 
an infant's food, as starch cannot be digested during the first 
months of life. It is useful when children are old enough to 
receive a farinaceous food. To this same class belong Horlick's 
food, Mellin's food, malted milk, Nestle's food, farina, and 
wheatena. 

ROOTS AND TUBERS 

Roots and tubers are much used as articles of diet and differ 
greatly in nutritive value. They are chiefly composed of starch 
or sugar. The most valuable of them is the potato. It con- 
tains about 80 per cent, of water, 18 per cent, of starch, approxi- 
mately 2 per cent, of nitrogenous matter, and 1 per cent, of 
mineral matter. The amount of fat that it contains is a small 
fraction of 1 per cent. Less than one-half of the nitrogenous 
matter in it is protein. Extractives (asparagin, etc.) constitute 
the remainder. The potassium salts that it contains are impor- 
tant for the prevention of scurvy. Potatoes can be kept well 
and carried long distances, especially at sea. A new or young 
potato contains less starch than an old one and relatively more 



Il6 VEGETABLE FOODS. 

nitrogenous matter. Potatoes are often boiled and stewed. 
Cooked in this way they lose much of their nitrogenous matter 
and mineral constituents. To retain these they should be 
baked or roasted in their skins. An old potato that is baked 
and mealy is the most digestible. Puree or mashed potato is 
almost or quite as easily digested. Potatoes stewed, boiled, 
fried, or cooked otherwise in chunks, and swallowed in con- 
siderable masses, are least digestible. Two boiled potatoes 
of average size will remain in the stomach about two and one- 
half hours. More than 90 per cent, of the starch in them is 
absorbed from the intestine. Potatoes contain a relatively 
small amount ot cellulose. They must be used in the same 
manner as bread — that is, to supplement meat and fats. The 
sweet potato has a similar composition, but a larger proportion 
of carbohydrate. Carrots are rich in sugar. They contain 
almost no starch and relatively a large amount of cellulose. 
Nitrogenous matter and fat occur in them in very small amounts. 
They are not easy to digest, and much of their constituents is 
lost in the feces. More than one-fourth of their sugar, which 
is their chief nutritive ingredient, is lost. A given weight of 
carrots will stay in the stomach an hour longer than the same 
quantity of potatoes. Parsnips and beets are similar to carrots 
in that they are rich in sugar, containing from 10 to 15 per cent, 
of it. They contain so little nitrogenous matter that it need not 
be taken into account. Onions are chiefly valuable because of 
their pungent oil, which is relished as a condiment. They also 
contain a considerable percentage of carbohydrate. 

Turnips have a small nutritive value, since they contain 
about 5 per cent, of a carbohydrate, which is neither starch nor 
sugar, but belongs to the group of bodies named pentoses. The 
changes that the latter undergo in digestion are not clearly 
understood. 

Tapioca, arrow-root, and sago are almost pure starches. The 
first two are derived from roots of tropic plants; the third, from 
the pith of the sago palm. Like rice, they are nutritious, and 
are probably almost completely absorbed from the intestine. 
Tapioca, however, is not quickly disposed of by the stomach. 
If a large plateful of it is eaten, it will not disappear completely 
from the stomach in less than two and one-half hours. 



LEGUMES. 



II 7 



PEAS AND BEANS 

Peas and beans differ from the other vegetable food-products 
thus far considered, in that they are rich in nitrogenous matter. 
They are frequently spoken of as good substitutes for meat. 
Their chief nitrogenous constituent is legumin, a protein, which 
in many of its chemical reactions resembles casein. They also 
contain much carbohydrate and little fat. Beans and peas 
are not quickly digested, and, as ordinarily cooked and eaten, 
are not very perfectly absorbed from the intestine. If they are 
simply boiled, a large plateful will not be disposed of by the 
stomach for from four to five hours. Forty per cent, of their 
protein will be lost in the intestine. However, if they are eaten 
after they have been ground to a fine flour, only 8 or 9 per cent, 
will be lost. They are most digestible when made into mush 
or prepared as a pur£e. They are highly nutritious, but should 
be supplemented by fats. String-beans and wax beans are eaten 
when young, and the pod as well as the bean is eaten. The 
former consists largely of cellulose. It contains little nourish- 
ment and is not easy to digest. Beans, especially dried beans, 
are likely to cause flatulence. This is in large part due to their 
slow digestion. They also contain sulphur and form sul- 
phureted hydrogen in the alimentary canal. 

The following table of analyses, taken from a bulletin of the 
United States Department of Agriculture, gives the composition 
of this important group of foods : 



COMPOSITION OF FRESH AND DRIED LEGUMES COMPARED WITH 
THAT OF OTHER FOODS 



Material. 


Water. 


Protein. 


Fat. 


Carbohy- 
drates. 


Ash. 


Fuel Value 
Per Pound. 








Per 




Per 




Fresh legumes: 


Per cent. 


Per cent. 


cent. 


Per cent. 


cent. 


Calories. 


String-beans, . . . 


89.2 


2-3 


0-3 


7-4 


0.8 


195 


Whole pods of Doli- 














chos sesquipedalis, . 


79-9 


45 


0.5 


13-9 


1.2 


365 


Sugar peas or string 














peas, 


81.8 


3-4 


0.4 


13-7 


O.7 


335 


Shelled kidney beans, 


58.9 


9 4 


0.6 


29.1 


2.0 


740 


Shelled Lima beans, . 


68.5 


7.1 


0.7 


22.0 


1.7 


57o 


Shelled peas, . . . 


74.6 


7.0 


0.5 


16.9 


I.O 


465 


Shelled cowpeas, . . 


65-9 


9.4 


0.6 


22.7 


1-4 


620 



n8 



VEGETABLE FOODS. 



Composition of Fresh and Dried Legumes Compared with that of Other 

Foods. — ( Continued.) 



Material. 


Water. 


Protein. 


Fat. 


Carbohy- 
drates. 


Ash. 


Fuel Value 
per Pound. 








Per 




Per 






Per cent. 


Per cent. 


cent. 


Per cent. 


cent. 


Calories. 


Canned string -beans, . 


93-7 


I.I 


O.I 


3-8 


1-3 


95 


Canned Lima beans, 


79-5 


40 


03 


14.6 


1.6 


360 


Canned kidney beans, . 


72.7 


7.0 


0.2 


18.5 


1.6 


480 


Canned peas, . . 


853 


3-6 


0.2 


98 


1.1 


255 


Canned baked beans, . 


68.9 


6.9 


2-5 


19.6 


2.1 


600 


Peanut butter, .... 


2.1 


29-3 


46.5 


17.1 


5-0 


2825 


Dried legumes : 














Lima beans, .... 


10.4 


18.I 


1-5 


65-9 


4.1 


1625 


Navy beans, 






12.6 


22.5 


1.8 


59-6 


3 5 


1605 


Frijoles, . . 






7.5 


21.9 


i-3 


65.1 


4.2 


1695 


Lentils, . . 






8.4 


25-7 


1.0 


59-2 


57 


1620 


Dried peas, 






9 5 


24.6 


1.0 


62.0 


29 


1655 


Cowpeas, . 






13.0 


21.4 


1.4 


60.8 


3-4 


1590 


Soybeans, . 






10.8 


34 


16.8 


33-7 


4.7 


1970 


Chick-pea, . 






14.8 


12.4 


67 


63-3 


2.8 


1690 


Peanuts, 






9.2 


25.8 


38.6 


24.4 


2.0 


2560 


St. John's bread (ca- 














rob bean), 




• • 


150 


59 


i-3 


75-3 


25 


1565 



GREEN VEGETABLES 



This group of vegetables contributes little to the nourishment 
of man. They are eaten chiefly because of their agreeable 
flavor and because they add variety to our diet. The amount 
of protein and fat that they contain is inappreciable, and their 
carbohydrates are in very small quantities. They possess 
mineral salts of value and sometimes organic acids. Oxalic 
acid, which occurs in considerable quantities in some of the 
green vegetables, makes them harmful to those who are prone to 
develop oxalic acid calculi. The large amount of cellulose they 
contain produces bulky feces, but stimulates peristalsis. Many 
of these vegetables are distinctly laxative. They contain from 
80 to 96 per cent, of water, which makes them a bulky form of 
food. For the most part they must be cooked, a process that 
softens the cellulose and makes them more digestible. A few are 
eaten raw. Certain of them cause flatulence; many do not. Cab- 
bages are especially prone to create a condition of flatulence. 
Green vegetables are antiscorbutics. 

Most green vegetables are not sufficiently digestible to be 



GREEN VEGETABLES. 



II 9 



good for invalids. If the functions of the stomach and in- 
testines are not greatly impaired , the blandest can be used . With 
the exception of lettuce, cabbage and tomatoes they should not 
be eaten raw. Spinach and celery boiled in milk, if finely 
chopped, are bland and agreeable. These articles do not ferment 
in the stomach or bowels to an appreciable extent, and can 
often be prescribed when other vegetables must be avoided. 

Penzoldt found that it required for from two to three hours 
for the stomach to dipose of 150 grams of boiled cauliflower or 
asparagus, three to four hours for the same quantity of carrots, 
kohlrabi, spinach, cucumber salad, and radish. The following 
table, taken from Hutchison, will give some idea of the com- 
position and food value of this class of foods : 



Water. 


Nitrogen- 
ous. 
Matter. 


Fat. 


Carbo- 
hydrates. 


Min- 
eral 
Mat- 
ter. 


Cellu- 
lose. 


89.6 


I.80 


0.40 


5.8 


I.30 


I. IO 


974 


O.60 


O.IO 


0.4 


0.13 


I.30 


90.7 


2.20 


0.40 


4-7 


O.80 


I.20 


93-3 


I 40 




3-8 


O.60 


0.90 


97-9 


O.40 


0.07 


0.3 


O.20 


1. 10 


90.6 


2.50 


0.50 


3-8 


I.70 


O.90 


94.8 


O.06 


0.20 


2.6 


O.50 


I.30 


99.2 


O.09 


0.04 


0.2 


0.05 


0.37 


93-7 


I.50 


O.IO 


3-4 


I.30 




91.9 


I.30 


0.20 


5-o 


0.70 


I.IO 


94.0 


1. 00 


0.20 


O.I 


O.70 


1.50 


82.9 


380 


0.90 


8.9 


350 




94.1 


I.40 


0.40 


2.6 


1.00 


0.50 


97.2 


O.50 


0.16 


0.5 


0.40 


0.90 


91.8 


I.20 


0.50 


5-8 


0.70 




93-4 


I.40 


O.IO 


33 


0.90 


0.90 


970 


0.30 


0.06 


0.8 


0.50 


1. 00 


87.1 


2.60 


0.20 


71 


1.50 


1.30 


94.6 


O 70 


0.70 


2-3 


0.60 


I.IO 


93 1 


I.40 




45 


1. 00 




93- 1 


0.70 


0.50 


3-7 


1.30 


O.IO 


959 


O.80 


10 


2.1 


0.40 


0.50 


97-4 


0.50 


0.02 


0.7 


0.20 


0.90 


91.7 


2.20 


0.20 


2.9 


90 


2.10 


87.2 


I.20 


0.08 


9.0 


0.30 


2.20 


94.0 


I. OO 




30 


0.80 


0.60 


87.0 


3 30 


0.70 


6.0 


1.60 


1.20 


90.0 


I.80 


0.19 


58 


0.70 


1.20 


91.0 


I.40 


0.70 


2.9 


1.70 


0.90 



Fuel 

Value 

per Pound, 

Calories. 



Cabbage, . . . 
Cabbage, cooked, 
Cauliflower, . . 
Sea-kale, . . . 
Sea-kale, cooked, 
Spinach, . . . 
Vegetable marrow, 
Vegetable marrow 

cooked, . . . 
Brussels sprouts, 
Tomatoes, . . 
Tomatoes, cooked, 
Greens, .... 
Lettuce, .... 
Lettuce, cooked, 
Leeks, .... 
Celery, .... 
Celery, cooked, 
Turnip cabbage, 
Rhubarb, . . . 
Macedoine (thinne 
Water- cress, 
Cucumber, . . . 
Cucumber, cooked 
Asparagus, . . 
Salsify, cooked, 
Endive, .... 
Savoys, .... 
Red cabbage, 
Sauer-kraut, . . 



d) 



165 
175 

X20 



95 

275 
105 

150 
85 

145 
105 
no 

70 



120 VEGETABLE FOODS. 



FRUITS 



Fruits can conveniently be classified as those that are eaten as 
a relish or to afford variety, and those that have food value. 
Their value as food is small, however. They are pre-eminently 
carbohydrates for their chief nutritive constituents are sugars, 
mostly levulose, or fruit-sugar, and cane-sugar. Many of them 
contain varying small amounts of a jelly-producing substance 
called pentose, the chemical nature and utility of which are not 
well understood. They contain numerous salts formed of 
potassium and sometimes of sodium, and magnesium, with the 
fruit acids, such as citric and malic. The flavors of fruits are 
due to oils and ethers. Very few fruits contain enough sugar 
to make them of much value as food. The most nutritious 
of the raw fruits is the banana. Many others become more so 
when they are concentrated by drying. For instance, fresh 
apples contain 12 per cent, of carbohydrate, but when 
dried, almost 50 per cent. ; dates and figs, more than 60 per 
cent. ; raisins, 74 per cent., but fresh grapes, only from 10 to 20 
per cent. 

Fruit is eaten, first, because it is appetizing and palatable; 
second, because it is refreshing, lessening thirst by its large 
amount of water; third, because of its nutritive properties; 
fourth, because of its salts and acids which make fruit an im- 
portant antiscorbutic; fifth, because some kinds possess 
diuretic properties, and sixth, because most of them possess 
laxative properties. 

Unripe fruit contains a relatively large amount of cellulose 
and of solid matter and a small amount of sugar. It is, there- 
fore, usually hard, sour, and indigestible. It lacks the flavor 
of ripe fruit. When fruit ripens it becomes juicier, and the 
starch in it is converted into soluble sugars. The acids that it 
contains are more dilute. The cellulose framework of fruit as it 
fills during the stage of ripening becomes thin, relatively soft, 
and easily broken by mastication and agitation. 

Cooking usually makes fruit more digestible, because it 
softens the cellulose and converts the gums (pectin) into a 
gelatinous mass. Nevertheless if stewed or cooked with water, 
fruits lose part of their nutritive ingredients. Apples lose 4 



FRUIT PRESERVES. 121 

per cent, of carbodydrates, pears about the same, and peaches 
7 or 8 per cent. 

Fruit is often cooked to preserve it, and cane-sugar is added 
to make it keep better. It is usually stewed, but is also often 
dried, which concentrates it by raising its percentage of sugar. 
Partial desiccation prevents its spoiling. Jellies are made from 
many fruits. They are useful condiments for invalids. Jams 
and marmalades are fruit sweetened and partly converted into 
jelly. Occasionally fruits are spiced and preserved in an acidi- 
fied (vinegar) syrup. In Germany fruit soups are often eaten. 
In the United States they are almost unknown. Fruit -juices 
and syrups are sometimes employed to flavor iced drinks, and 
are often grateful to invalids, and, if not drunk in too large 
quantities, are wholesome. All these preparations are used 
because of their agreeable flavors rather than for their nutritive 
value. From the banana, a meal is made by drying and grind- 
ing it. In nutritive power it is quite equal to the same quan- 
tity of rice. It is agreeable, easy to digest, and very thoroughly 
absorbed. Those who have digestive disorders that make the 
stomach and bowels intolerant can use it because it is so bland. 
It is, therefore, a useful addition to the list of bland foods, such 
as sago and arrow-root. Banana flour contains little or no 
starch but an abundance of sugar. It is not used so much as 
it might well be. 

Ripe fruits, stewed fruits, and jellies are usually very diges- 
tible. If taken in too large quantities, they often ferment in 
the alimentary canal and produce colic and gastro-enteric 
disorders. Unripe or overripe and spoiled fruit is especially 
prone to cause these disturbances. The time during which 
fruit remains in the stomach and its absorbability by the in- 
testine have not been thoroughly studied. A large apple does 
not pass out of the stomach for more than three hours. Many 
fruits are marketed before they are ripe, and are allowed to 
ripen partly afterward. These are much less digestible than 
they would be if eaten when ripe. The acids of many fruits 
make them indigestible to those who suffer from acid fermenta- 
tion in the stomach. Occasionally a person is met with who 
possesses an idiosyncrasy, and who, after eating certain fruits, 



122 



VEGETABLE FOODS. 



will have gastroenteric troubles, hives, or other evidence of 
poisoning. The seeds of berries often irritate the intestines. 

Apples, pears, and even more often figs, dates, and prunes, are 
employed as laxatives. The laxative effect is most noticeable 
when these fruits are eaten the last thing at night or the first 
thing in the morning, at a time when the stomach contains 
little or no food. They are least effective when they are eaten 
at the end of a meal or with a full meal. The very acid fruits, 
such as lemons, grape-fruit, and oranges, are least laxative. 
Most berries must be classed as intermediate between these two 
groups, so far as laxative properties are concerned. 

When the 'grape cure* is taken in Germany, from one to eight 
pounds of grapes are eaten daily, and little or no other food 
for a time. At first, a small quantity is eaten, but day by day 
it is increased. Those who take this 'cure' are expected to 
pick the grapes for themselves, which insures outdoor life and 
gentle exercise. It is a mode of treatment chiefly adapted to 
the obese and to those who lead a sedentary life. 

The acids contained in fruits often have much to do with their 
digestibility. In health apples and strawberries can usually 
be eaten with impunity but in some gastric disorders the malic 
acid in them and other fruits makes them unwholesome. More 
than one acid is contained in some fruits, though one usually 
predominates. Apples, blackberries and strawberries contain 
malic acid; currants and grapes tartaric acid; and oranges, 
lemons, grape fruit, and gooseberries, citric acid. Of these 
the citrous fruits are the best tolerated by all persons. 

SUGAR AND ACID CONTENT OF COMMON FRUITS 1 

Sugar Acid 
Apples : — 

Greening 10 . 95 .70 as Malic. 

Winesap 1 1 . 95 .50 as Malic. 

Northern Spy 1 1 . 80 .70 as Malic. 

Apricots : — 

Fresh 11. 01 1.15 as Malic. 

Dried 2 9-59 2.52 as Malic. 

Bananas 20.28 .3 as Sulfuric. 

Blackberries 5-78 .77 as Malic. 

Cranberries 1.52 2 . 34 as Malic. 

1 "Poods and Their Adulterations." Wiley, 1911. 



OLIVES. 



123 



Sugar 



Currants 6 

Grapes 7 

Lemons 

Oranges 5 

Grape fruit 9 

Peaches 7 

Pears 9 

Pineapples 11 

Plums 14 

Prunes 16 

Raspberries 5 

Olives 



7 

9 

37 

65 

5 

88 

1 1 

5 

71 

1 1 

33 



Acid 
2 .24 
•59 
5-39 
i-35 
2.7 

•56 
.19 
.6 
•77 
•32 
1.48 



as Malic, 
as Tartaric, 
as Citric, 
as Citric, 
as Citric, 
as Sulfuric, 
as Malic, 
as Sulfuric, 
as Malic, 
as Malic, 
as Malic. 



Two food products of considerable importance are made from 
olives — namely, olive oil, or salad oil, and pickled olives. A 
third product, little known in America, is the dried olive, much 
eaten in Greece and some neighboring countries. All olive oil 
and pickled olives were formerly imported, most generally 
from southern Europe. In recent years California has devel- 
oped olive growing. 

The ripe olive fruit is not unlike an oval damson plum in 
form and size. In color it ranges from various shades of purple 
to almost black. It has a sour and persistent bitter flavor. 
Both pulp and pit contain oil. The amount of oil in the pulp 
in different samples ranges from 13 to about 88 per cent.; that 
in the pit, from 0.36 to 1.52 per cent. 

Whether used for oil making or pickling, the olive should be 
carefully gathered. The ripe fruit is used for oil making and 
for pickling; the exact stage when it is best suited for this 
purpose must be learned by experience. The green fruit is 
also used for pickling and should be gathered when full grown 
and just before it begins to color and soften. The pickled olives 
usually found in the American market are made from the green 
fruit. The pickled ripe olives are also met with and may be 
recognized by their dark color. 

The best oil is made by crushing the carefully picked fresh 
olives. To facilitate the extraction of the oil, the olives are 
often partially dried before crushing. Old-fashioned stone mills 
are commonly used to crush the fruit, although bronze crushers 
are sometimes employed. The ground mass is pressed to ex- 



124 



VEGETABLE FOODS. 



tract the liquid portion, which contains watery plant juices in 
addition to the oil and more or less pulpy matter. Various 
devices are used to separate the oil and to purify it. It is said 
that the best oil is obtained by allowing the pulp, etc., to settle, 
and decanting the clear oil. It generally takes about one month 
for oil to settle the first time. It is usually decanted three 
times. The oil thus obtained is almost as bright as can be 
produced by the most effective filtration, and it has, besides, 
the distinctive olive flavor and lacks the greasiness that is 
characteristic of all filtered oils. Great cleanliness must be 
observed in oil making and every precaution taken to avoid 
rancidity. 

Essentially the same process is followed in making pickles, 
whether from ripe or green olives. The unpleasant acid and 
bitter flavor is removed by soaking the fruit in a solution of 
potash lye for a short time or by longer soaking in water. The 
lye also softens the skin, so that the undesirable substances 
may be more readily extracted by water. Olives treated with 
lye must be soaked in clear water, which is frequently changed, 
to remove the potash. They are then placed in a weak brine 
for a short time and afterward in stronger brines. The details 
of each step of the process vary considerably, and much de- 
pends upon skill and experience. An abundant supply of pure 
water is of the first importance, and great care must be exer- 
cised to prevent the growth of molds, etc. As in the manufac- 
ture of oil, cleanliness is a prime requisite. 

The uses of olive oil and olives as articles of diet are familiar. 
The former is used chiefly for salad dressing and for frying; 
the latter as a relish for seasoning sauces, etc., and for garnish- 
ing various foods. The oil, like all fats, has a high fuel value, 
and on this its value as a food depends. 



COMPOSITION OF PICKLED RIPE AND GREEN OLIVES 



Water 



Fat (Oil) 



Carbohy- 
drates 



Protein, 
Ash, etc. 



Pickled ripe olives, . . 
Pickled green olives, 



Per cent. 
65.08 

78.41 



Per cent. 
25-52 
12 .90 



Per cent. 
3-75 
I.78 



Per cent. 
5.65 
6 .91 



COMPOSITION OF FRUITS 



125 



Green olives are simply a relish and to be used in very lim- 
ited quantities in the same way as pickled walnuts or cucumbers. 
A meal of bread and ripe olives is not only palatable, but nutri- 
tious and sustaining, and the amount eaten is to be limited only 
by the same considerations as that of any other good, whole- 
some food. In southern Europe and other regions the ripe 
olive is used as a staple article of diet. 

The following table will show the composition of most 
fruits. From one-half to three-fourths of the carbohydrates 
in them is sugar. In this table, taken from Hutchison, the 
cellulose is sometimes included with the other carbohydrates 
and sometimes estimated separately. 





Water. 


Protein. 


Ether 
Extract. 


Carbohy- 
drates. 


Ash. 


Cellu- 
lose. 


Acids. 


Apples, .... 


82.5 


0.4 


05 


12-5 


0.4 


2.7 


1.0 


Apples, dried, . 


36.2 


1.4 


3.0 


49-1 


1.8 


4-9 


3-6 


Pears, .... 


83-9 


0.4 


0.6 


"5 


0.4 


3-1 


0.1 


Apricots, . . . 


85.O 


I.I 




12.4 


05 




1.0 


Peaches, . . . 


88.8 


o-5 


0.2 


5-8 


0.6 


3-4 


0.7 


Green gages, . 


80.8 


0.4 




13-4 


0.3 


4.1 


1.0 


Plums, .... 


78.4 


1.0 




14.8 


0.5 


4-3 


1.0 


Nectarines, . . 


82 9 


0.6 




15-9 


0.6 






Cherries, . . . 


84.0 


08 


O.8 


100 


0.6 


3-8 


1.0 


Gooseberries, . 


86.0 


0.4 




8.9 


0.5 


2.7 


»-5 


Currants, . . . 


85.2 


0.4 




7-9 


o-5 


4.6 


1.4 


Strawberries, ; 


89.1 


1.0 


OS 


6-3 


0.7 


2.2 


1.0 


Whortleberries, 


76.3 


0.7 


3° 


5-8 


0.4 


12.2 


1.6 


Blackberries, 


88.9 


0.9 


2.1 


2-3 


0.6 


5.2 




Raspberries, . . 


84.4 


1.0 




5-2 


0.6 


7-4 


1.4 


Cranberries, . . 


86.5 


0.5 


0.7 


3-9 


0.2 


6.2 


2.2 


Mulberries, . . 


84.7 


0.3 




11. 4 


0.6 


0.9 


1.8 


Grapes, .... 


79.0 


1.0 


1.0 


15-5 


o-S 


2-5 


0.5 


Melons, . . . 


89.8 


0.7 


03 


7.6 


0.6 


1.0 




Watermelon, 


92.9 


°-3 


O.I 


6-5 


0.2 






Bananas, . . . 


74.0 


i-5 


0.7 


22.9 


0.9 


0.2 




Oranges, . . . 


86.7 


0.9 


0.6 


8-7 


0.6 


1.5 


1.8 


Lemons, . . 


89-3 


1.0 


0.9 


8-3 


o-S 






Lemon-juice, 


90.0 






2.0 


0.4 




7.0 


Pineapples, . . 


89.3 


0.4 


0.3 


9-7 


o-3 






Dates, dried, 


20.8 


4.4 


2.1 


657 


i-5 


5-5 




Figs, dried, . . 


20.0 


5-5 


O.9 


62.8 


2-3 


7-3 


1.2 


Figs, fresh, . . 


79 1 


i-5 




18.8 


0.6 






Prunes, dried, . 


26 4 


2.4 


O.8 


66.2 


i-5 




2.7 


Prunes, fresh, . 


80.2 


0.8 




185 


°-5 






Currants, dry, . 


27.9 


1.2 


3-0 


64.0 


2.2 


i-7 




Raisins, .... 


14.0 


2-5 


4-7 


74-7 


41 







126 



VEGETABLE FOODS. 



NUTS 

Nuts are eaten almost exclusively for dessert. They are 
agreeable, but have little value as food. They contain a large 
amount of oil, a moderate amount of carbohydrate, and rela- 
tively a large amount of protein. Chestnuts are an exception to 
this general statement, for they contain only a small percentage 
of oil and a large percentage of carbohydrate. Nuts are 
variously estimated by writers upon dietetics. I do not know 
of any careful study of their digestibility. Owing to their high 
fuel value and low protein contents they will not make a well- 
balanced food when eaten by themselves. As they are usually 
eaten raw and as they contain a large amount of cellulose, they 



COMPOSITION OF NUTS AND SOME OTHER FOOD MATERIALS. 



Nuts, etc. 



Almonds, 

Brazil nuts, 

Filberts, 

Hickory nuts, 

Pecans, 

English walnuts, 

Chestnuts, fresh, 

Chestnuts, dried, 

Acorns, 

Beechnuts, 

Butternuts, 

Walnuts, 

Cocoanut, 

Cocoanut, shredded, . . . 
Pistachio, kernels, .... 
Pine nut or piiion (Pinus 

edulis), 

Peanuts, raw, 

Peanuts, roasted, 

Litchi nuts, 

Beefsteak, 

Wheat flour 

Potatoes, 



Refuse, 



Per cent. 
64.8 
49.6 
52.1 
62.2 

53-2 
58.0 
16.0 
24.0 
35-6 
40.8 
86.4 
74.I 
48.8 



40.6 

24.5 
32.6 
41.6 
12.8 



Edible 
Portion 



Per cent, 

35-2 
5o.4 
47-9 
37-8 
46.8 
42.0 
84.0 
76.0 
64.4 
59-2 
13-6 
25-9 
512 
100.0 
100.0 

59-4 
75-5 
67.4 
58.4 
87.2 
100.0 

80.0 



Composition and Fuel Value of the 
Edible Portions. 



Water. 



Per 

cent. 

4.8 

5-3 
3-7 
3-7 
3-o 
2.8 

45-o 
5-9 
4.1 
4.0 
4-5 
2-5 

14. 1 

3-5 
4.2 

3.4 
9.2 
1.6 
17.9 
61.9 
12.8 
78.3 



Pro- 
tein. 



Per 
cent. 
21. 
I7.0 
15.6 

15-4 

II. O 

16.7 

6.2 

10.7 

8.1 
21.9 
27.9 
27.6 
5-7 
6-3 
22.6 

14.6 
25.8 
3o-5 

2.9 
18.9 
10.8 

2.2 



Fat. 



Per 
cent. 

54-9 
66.8 

65-3 
67.4 
71.2 
64.4 

5-4 

7-o 

37-4 

57-4 

61.2 

56.3 
50.6 

57.3 
54-5 

61.9 

38.6 

49.2 

0.2 

18.5 

1.1 

0.1 



Carbo 

hy- 

drates 



Per 

cent. 

17.3 

7.0 

13.O 

II.4 

13-3 
I4.8 
42.I 
742 
48.O 
13.2 
3-4 
11.7 
27.9 
31-6 
i S .6 

17-3 
24.4 
16.2 
77-5 

74.8 
18.4 



Ash. 



Per 
cent. 
2.0 

3-9 
2.4 
2.1 

1-5 

'•3 
13 

2.2 

24 
3-5 
30 
1.9 

i-7 

i-3 
3* 

2.8 
2.0 

2-5 

15 
1.0 

0.5 

1.0 



Fuel 
value, 

per 
Pound. 



Per 
cent. 

*3°3<> 

3329 
3432 

3495 

3633 

*33<>5 

1125 

1875 
2718 
3263 
337i 
3105 
2986 
*3i25 
*3oio 

3364 
*256o 

3177 
1453 
1130 
1640 
*3*5 



* These values were calculated ; unless otherwise indicated the fuel values were 
determined. 



FUNGI AND ALGjE. 1 27 

are not easily disintegrated or prepared for digestion. The 
large amount of oil in them quickly causes a feeling of satiety, 
as do other oils. They are usually eaten after hearty meals, 
as a part of the dessert. These are conditions that are least 
favorable to their digestion. They are often chopped and used 
in salads, as a relish in sandwiches, or as a part of the stuffing 
of fowl. They are also commonly used in confectionery. 
From certain pine nuts, and from the cocoanut, flours can be 
made that are valuable especially for diabetics, as they can be 
made into bread containing practically no starch or sugar. 
The preceeding analysis is taken from Bulletin No. 122 of the 
United States Department of Agriculture. 

FUNGI AND ALGJE 

Fungi are sometimes described as "vegetable, steak, and 
roast beef," and the poor are urged to eat them for economy. 
This is an exaggerated estimate of their value. It is true that 
they contain a large amount of nitrogenous matter; a con- 
siderable percentage of it, however, is not protein. They 
contain a small amount of carbohydrate, the exact nature of 
which is not understood, but which is not believed to be 
nutritious. Their abundant framework of cellulose helps to 
make them indigestible. When cooked, they contract and 
become tougher. From 30 to 50 per cent, of the protein in 
them is not digested or absorbed from the intestine. They 
must, therefore, be classed with other wasteful foods. They 
are not adapted to the use of most invalids, but have the 
valuable quality of adding variety to the limited list of foods 
that may be eaten by diabetic patients. They are also agree- 
able additions to the dietary of the healthy. The amount of 
protein in different varieties of fungi varies from 2 to 5 per 
cent. 

The differences between edible and poisonous mushrooms 
and other fungi will not be described here. Of the many 
hundreds growing in this country, only a few are commonly 
eaten. Excellent descriptions of these will be found in Bulletin 
No. 15 of the United States Department of Agriculture. 

The only alga commonly employed as a food is Irish moss. 



128 VEGETABLE FOODS. 

Its chief ingredient is a mucilaginous substance that can be 
dissolved or softened by hot water, and, when cooked, becomes 
a yellowish jelly. It is not acted upon by any of the digestive 
ferments and probably has no value as a food. It is bland and 
soothes an irritable throat, stomach, or intestine. Sugar and 
cream may be added to it or eaten with it. It is a pleasant 
addition to the limited dietary of diabetics. 

Iceland moss is a lichen that is used by cooks, as Irish moss is. 
It is likewise without value as a food. 

SPICES AND CONDIMENTS 

A word must be said of this group of adjuvants to food. 
They possess no nutritive value, but often aid digestion by 
stimulating the organs to secrete digestive juices in larger 
amounts and they make food more palatable. The most im- 
portant of them are mustard and pepper. Various spices and 
condiments are employed, chiefly for their flavor or for certain 
oils, such as vanilla and lemon. Sugar is of great value both 
as a food and as a condiment for it makes food more palatable. 
Saccharin and dulcin must be substituted for sugar when the 
latter is not well digested or assimilated. They are, however, 
condiments, and not foods. Vinegar is useful both as a flavor- 
ing agent and because it helps to soften hard muscle-fibers 
and cellulose. For the latter purpose it is frequently added 
to preparations of lobster and to raw green vegetables, such 
as lettuce, celery, sorrel, cucumbers, and tomatoes, when used 
as salads. 



CHAPTER IX 
BEVERAGES 

Tea. Coffee. Cocoa. Alcoholic Beverages. 

The necessity for water, and its various uses, have already 
been discussed. Other beverages are drunk because they are 
agreeable to the taste or are stimulants or anesthetics. Most 
uncivilized as well as civilized peoples use beverages that will 
either stimulate them, and thus relieve a sense of fatigue, or 
anesthetize them — that is, make them less conscious of it. If 
the habit of using these beverages be acquired, they are often 
taken when they are not needed, or in quantities larger than is 
necessary, and sometimes even to an extent that is harmful. 

TEA 

Tea has been used by Europeans for about three hundred 
years. It is employed in the United States extensively, but 
not so much as in England, in the British colonies, and in 
Russia. 

Many varieties of tea can be purchased. These depend for 
their peculiarities upon the plant from which they are obtained, 
upon the season of the year when the leaves are gathered, and 
upon the age, tenderness, and juiciness of the leaf. Tea-leaves 
were primarily culled from two species of plants, Thea chinensis 
and Thea assamica. Now, however, there are numerous 
hybrids. Teas grown in China, Japan, India, and Ceylon vary 
somewhat in flavor. The finest tea is made from the small 
tender leaves at the end of new shoots, each succeeding pair of 
leaves upon the branch furnishing a different and less valuable 
grade. Three or four pairs of leaves or grades are gathered. 
The various kinds and grades of tea are classified as green or 
black, according to the method adopted for curing them. 
Black tea is made by 'withering' the freshly picked leaves in 
9 129 



130 BEVERAGES. 

the sun. They are then mashed and rolled in order to break 
the fiber and cells of the leaf and liberate their constituents. 
After this the leaves are gathered together and fermented, dur- 
ing which process a part of the tannic acid in them is made less 
soluble and the essential oils are modified in character. They 
are again exposed to the sun, and finally * fired ' or dried in an 
oven. Green teas are withered in pans that are at a tempera- 
ture of 160 F.; in Japan they are steamed. They are then 
rolled, withered again, sweated in bags, and finally slowly 
roasted. These processes of manufacture modify the compo- 
sition of the product. The following table shows these changes : 

Black Green 

Tea Tea 

Water 8.20 5-96 

Caffein 3 . 24 2.33 

Albumin 17.90 1 7 . 63 

Alcoholic extract 6.79 7 . 05 

Dextrin 0.50 

Pectin and pectic acid, 2 . 60 3.22 

Tannic acid 16.40 27.14 

Chlorophyll and resin 4 . 60 4.20 

Cellulose 34 . 00 25 . 90 

Ash 6.27 6.07 

The nutritive ingredients of tea are insignificantly small. 
Them, chemically the same as caffein, and tannic acid are the 
ingredients that are physiologically active. The aroma and its 
variations are produced by volatile oils. 

In the process of manufacture of green tea the quantity of 
water and of caffein in it is lessened, and the tannic acid is 
much increased in amount. In general it may be said that 
teas contain fron 2 to 4 per cent, of thein or caffein and from 10 
to 25 per cent, of tannic acid. Caffein is responsible for the 
feeling of nervous stimulation that tea-drinkers experience. 
Tannic acid affects digestion chiefly in a detrimental manner. 
It is, therefore, important so to prepare tea as a beverage that 
it will contain a maximum quantity of caffein and a minimum 
quantity of tannic acid. To accomplish this more depends 
upon the manner of brewing than upon the variety of tea. 
Caffein is extracted from the leaves at once when boiling water 
is poured upon them, but tannic acid is extracted much more 
slowly. Almost one-third more tannic acid is obtained in the 



COFFEE. 131 

beverage if the leaves stand in hot water thirty minutes than 
if they are in it only five. The difference in the percentage of 
caffein in the two infusions is slight. As ordinarily made, a cup 
of tea contains about one-tenth as much thein or caffein as a 
cup of coffee. 

The beverage tea, is made by pouring boiling water upon 
tea-leaves. The mixture should stand where it can be kept 
hot, but not boiling, for from three to five minutes. The water 
should be fresh, not very hard, and just brought to a boil. 
Stale water, very hard water, and water that has been sub- 
jected to prolonged boiling and from which, in consequence, 
all air has been driven does not make so agreeable a beverage. 
Some inveterate tea-drinkers keep the tea-pot with water and 
tea-leaves in it upon the stove constantly and frequently drink 
the beverage that is thus made. It contains a large amount 
of tannic acid and is most unwholesome. The tannic acid in 
concentrated solution precipitates the pepsin of the gastric 
juice and prevents digestion. In weaker solution it often makes 
digestion slow. When taken upon an empty stomach, it acts 
as an astringent, lessening the secretions from the mucous 
membranes. In the intestines it is an astringent and often 
causes or aggravates constipation. 

Tea should not be used by dyspeptics or by those who are 
constipated. When taken in too large amounts, it will produce 
wakefulness, nervousness, excitability, and even muscular un- 
steadiness or twitching. The digestive disorders due to its 
tannic acid are much more pronounced when tea is drunk to 
excess than its stimulating effects. Flatulence, gastric distress, 
constipation, often cardiac irregularity, pleurodynia, and 
sleeplessness are the predominant symptoms of excessive 
tea-drinking. 

Tea is not disposed of by the stomach so rapidly as water. 
It is estimated that a pint of the latter is evacuated into the 
intestine within an hour. Half as much tea remains in the 
stomach for from one to two hours. 

COFFEE 

Coffee was introduced into Europe a few years later than tea. 
It is derived from Coffea arabica. The seeds, which are used 



132 BEVERAGES. 

in the manufacture of the beverage, develop in pairs in a fruit 
that resembles a cherry. Different varieties of these seeds or 
beans are produced in different countries, each having a char- 
acteristic flavor. 

To make the bean brittle, so that it may be ground easily, 
and to develop its flavor more perfectly, it is roasted. This 
should be done shortly before it is used, as the flavor is lost by 
keeping. Roasting causes a loss of from 5 to 20 per cent, of 
the caffein. The small amount of saccharine matter that coffee 
contains is also almost completely lost. Mocha in the raw- 
state contains 9.55 per cent, of this, and when roasted, only 
0.43 per cent. The fats or oils in it are increased. The most 
important of these oils is caffeol, which gives to roasted coffee 
its aroma. If two ounces of powdered coffee are used to make 
a pint of the beverage, the latter will contain approximately 
3.5 grains of caffein and 6.5 grains of tannic acid. Each cup- 
ful will contain about one-half as much. Caffein is chemically 
trimethylxanthin and is closely related to xanthin, uric acid 
and the other purin bodies. 

Coffee is frequently adulterated; such substances as peas, 
beans, acorns, and, more frequently, chicory are used for this 
purpose. The last is thought by many to modify the flavor 
of coffee agreeably, and it is not detrimental. Caramel is also 
occasionally used as an adulterant. 

The beverage is made in several ways: Sometimes boiling 
water is filtered through finely ground coffee. By this proc- 
ess, however, one-half less of the coffee is dissolved than by 
the other methods. It may be infused, the ground coffee being 
put into boiling water and allowed to stand in it for some min- 
utes in a hot place, but without boiling. In Turkey, coffee- 
beans are powdered and a decoction is made from them by 
putting the powder in cold water, which is then heated to boil- 
ing. This beverage is not strained. If coffee is boiled for 
some time, it loses its aroma, contains a larger percentage of 
tannic acid, and becomes more indigestible. 

Both the caffein and the oil in coffee are stimulants. Caf- 
fein affects especially the central nervous system. Under its 
influence mental processes are quickened, the mind is made 
wakeful and restless, and if a sense of weariness exists, it is 






COCOA. 133 

lessened. Respiration grows deeper, the heart beats with more 
force and rapidity and the pressure of blood in the arteries is 
increased. Coffee is a mild laxative to some persons. It in- 
creases tissue waste. In no sense is either tea or coffee a food, 
but sugar and milk added to them may give them food values. 

Coffee is variously tolerated by different persons. Those who 
are nervous are made more so, and they are often made sleep- 
less by it. Others feel only an agreeable stimulation. Many 
acquire a tolerance of coffee that makes them unconscious of 
its ill effects. Dyspeptics generally cannot drink it, especially 
if cream and much sugar are added to it. It is comparatively 
seldom that illness caused by coffee-drinking is seen, although 
it is not uncommonly observed from excessive tea-drinking. 
Soldiers and other bodies of men subjected to severe physical 
strain depend upon coffee to lessen their consciousness of fa- 
tigue. As a rule, they prefer it to tea. Its use improves the 
feeling of well being in soldiers so quickly that their officers 
regard it as a necessity. 

Numerous substitutes for coffee and tea have been devised. 
The substitutes for the former are usually made from grains. 
They possess a somewhat similar aroma and flavor, but do 
not contain caffein or other stimulating properties. They are 
not, however, better digested than coffee. Mate, or Paraguay 
tea, is extensively used in South America. It is a native prod- 
uct, containing a small amount of caffein and considerable 
tannic acid. It produces the same ill effects that tea does, 
but it is drunk in a very dilute form and before the tannic acid 
has been extracted ; therefore large amounts can be taken with 
comparative safety. 

COCOA 

Cocoa was introduced into Europe about one hundred years 
before tea and coffee were. The cocoa which is made into the 
beverage of the same name is made from the seeds of Theo- 
broma cacao. They develop in a pulpy fruit that somewhat 
resembles a cucumber. They are gathered into heaps in a 
warm, moist place and permitted to ferment. This process 
darkens the beans, lessens a bitter taste that they have at 



134 BEVERAGES. 

first, and loosens any pulp adhering to them. Afterward they 
are roasted in order to make them brittle and to loosen their 
husks. They break readily into halves called cocoa nibs. The 
latter contain about 50 per cent, of fat or cacao-butter, some 
starch and albuminous matter, but very little protein, a little 
cellulose, and from 1 to 3 per cent, of alkaloids and some oxal- 
ates. The active principle, theobromin or dimethylxanthin is 
closely related to caffein. 

The beverage cocoa differs from tea and coffee in that it is 
nutritious as well as stimulating. Its food value is due to the 
fat that it contains. The starch and protein are too inconsid- 
erable in amount to be of much worth. The beverage usually 
is made with milk, and sugar is added to it in varying quantities. 
These additions increase its nutritive properties very much. 
Ten grams of cocoa, the amount usually used to make a cupful, 
yields fifty to seventy calories. When made with milk and 
sugar, the beverage will yield 400 calories. The stimulating 
effect of theobromin, the chief alkaloid of cocoa, is different 
from that of caffein, to which it is chemically allied, in that it 
does not cause sleeplessness or muscular tremors. Under its 
influence the mind does not become so alert, but it relieves a 
feeling of muscular fatigue in much the same way. The exces- 
sive use of cocoa does not produce the nervous symptoms that 
tea and coffee do, though it is likely to cause indigestion because 
of the large amount of fat in it and sugar added to it. If the 
beverage is not made too rich with cocoa and not too sweet, it 
is digestible, somewhat nutritious, and mildly stimulating. It 
is much better adapted for use by children than tea or coffee, 
which should not be given to them at all. Cocoa cannot be 
used by persons who find it difficult to digest fats. It is an 
agreeable and useful beverage for convalescents, but can rarely 
be used by those whose gastric digestion is disturbed or 
enfeebled. 

Cocoa nibs are ground, and often a part of the fat is removed 
from them when they are prepared for the retail market. 
Chocolate is cocoa to which sugar, starch, and flavoring, usually 
vanilla, have been added. It contains commonly more than 
50 per cent, of sugar. To both cocoa and chocolate an alkali 
is frequently added to make them more soluble or more easily 



ALCOHOLIC BEVERAGES. 



135 



suspended in water, for cocoa goes into solution very imper- 
fectly. The fat in it and most of the other ingredients are 
suspended in water or milk, whichever may be used as a vehicle. 
An alkali converts a little of the fat into soap, which helps to 
emulsify the remainder. 

Cocoa is quite as quickly disposed of by the stomach as tea 
or coffee. Two hundred cubic centimeters, or a cupful of any 
one of them, disappears from the stomach in a little less than 
two hours if they are made with water, and in two and a half 
hours if cocoa is made with milk. 

The following analyses of a few of the preparations of cocoa 
and chocolate on the market will give a better idea of their 
average composition. 





Moisture Fat 


Nitrogenous 
Matter 


Other In- 
gredients 


Ash 


Cadbury's cocoa 

essence. 
Van Houten's pure 

cocoa. 
Epp's prepared 

cocoa. 

Epp's cocoa 

Van Houten's choc- 


3-9 
3-0 
4-9 
4-7 


25.2 
28.0 

15. 1 

33- 2 
27.5 

21.3 

21 .2 


20.9 

20.5 

6.7 

18.6 
3-9 


45-2 

39-7 

71.8 

36.7 


4.8 
8.8 

6.8 
1.8 


olate. 
Chocolat Menier . . . 




1.4 
i-9 


Plain chocolate 




7-8 









ALCOHOLIC BEVERAGES 



Ethyl alcohol is the active principle of alcoholic beverages. 
It is produced by fermenting sugars with yeast. The differ- 
ence in these beverages is due in part to the kind of sugar used, 
in part to the kind of ferment, and largely to by-products of 
fermentation that help to give flavor to them. 

Alcoholic beverages do so much harm that their utility under 
any circumstances has been denied. It is true that they are 
unnecessary as beverges and even as medicines, for there are other 
things that can produce all the good results ascribed to them, 



I36 BEVERAGES. 

but they do excite definite physiologic effects that are often 
forgotten because of their common use as drinks. 

A man in health does not need to use alcohol; but it is so 
extensively employed the world over either to produce factitious 
exhilaration, or, by lessening sensibility, to mitigate fatigue and 
discomfort, sorrow and suffering, and it has been so largely and 
often so injudiciously used in disease, that it demands consid- 
eration. As the physiologic effects of beverages containing 
alcohol are due practically to this factor alone, it seems well to 
discuss these effects before describing the various forms of 
alcoholic beverages. 

Alcohol is a poison to protoplasm which checks the activities of 
living matter and may kill it. By a rapid abstraction of water 
it precipitates albumin. The latter may be quickly redissolved 
in water if it has not been left too long in the alcohol. After a 
certain time resolution is impossible. When alcohol is taken 
into the mouth, it causes a sense of warmth in the mucous 
membranes, causes them to be unusually congested, and forms 
upon the surface a pellicle of precipitated albumin that is rapidly 
washed off by the saliva. The latter is formed in unusually 
large amounts because of the irritation of the mouth by the alco- 
hol. In contact with the mucous membranes of the stomach 
it causes similar changes. It also increases the formation of 
gastric juice, provokes more vigorous peristalsis of the stomach, 
induces congestion of its mucous membrane, and thus excites 
an excessive secretion of mucus. If a large amount of con- 
centrated alcohol is swallowed, it will produce acute inflammation 
of the stomach. If moderate amounts are taken frequently, 
and especially upon an empty stomach, it will gradually cause 
subacute inflammation. 

The chemical changes of digestion are not affected by very 
dilute solutions of alcohol. Five to 10 per cent., however, 
retards them, and 20 per cent, stops digestion. Strong alco- 
holic solutions precipitate the pepsin of the gastric juice and 
coagulate the albumin of foods, making them less soluble. 
Pancreatic digestion is more easily affected by alcohol than is 
peptic digestion. From 2 to 3 per cent, will retard it. Two 
tablespoonfuls of brandy delay the digestion of a meal in the 
stomach for a half-hour. 



PHYSIOLOGIC ACTION OF ALCOHOL. I37 

Small doses of alcohol may be beneficial, stimulating the 
secreton of gastric juice and increasing peristalsis. For this 
reason it has been used when the stomach is weak and is doing 
its work imperfectly. When the stomach is inflamed, alcoholic 
beverages aggravate the condition. Certain of them produce 
acidity, as will be explained later, and are therefore counterin- 
dicated in many digestive disorders. Intoxicating doses 
interfere with digestion because of the nervous and vascular 
depression that they cause. Alcoholic beverages habitually 
used in generous amounts cause sufficient irritation of the 
mucous membrane to give rise to the formation of an excess of 
mucus that, enveloping food particles, prevents the digestive 
juices from gaining access to them, and, by coating the interior 
of the stomach, lessens the secretion of gastric juice. 

Alcohol is readily absorbed from the stomach. It undergoes 
no change before being taken into the blood. By the portal 
vessels it is carried to the liver and thence into the general 
circulation. When alcohol is absorbed from the stomach, it 
provokes a counterflow of water from the tissues into that 
organ four times as great as its own weight. 

After absorption into the blood it forms a compound with 
hemoglobin, which causes that body to part with its oxygen 
more slowly than is natural. This in part explains the dis- 
turbed metabolism that exists after taking alcohol. 

Imbibed in small amounts, alcohol causes the heart to beat 
faster and more forcefully. These effects are often noticeable 
before the beverage has been absorbed; in that case they are 
caused reflexly by irritation of the mouth, for they are also 
produced by sipping other pungent or hot fluids. In the 
arterioles it causes a muscular relaxation or loss of tone. Be- 
cause of this the blood flows more readily from the arteries into 
the veins, blood pressure is lowered, and the heart beats faster. 
The pulse seems bounding, because in the intervals between the 
beats it is so completely emptied, the blood flowing rapidly into 
the capillaries and veins. The pulse is typically dicrotic. The 
habitual use of alcoholic beverages often produces persistent 
vascular paralysis. This is seen in the full red capillaries of the 
cheeks and noses of steady drinkers. Alcohol is often used 
because of its effects upon heart and blood-vessels. It helps to 



138 BEVERAGES. 

make the circulation more uniform and the heart beat faster and 
more effectively if the drug be given when the skin is blanched, 
the pulse small and hard, and the heart feeble. These conditions 
are met with in collapse, and occasionally in acute diseases 
accompanied by intense congestion of viscera, and sometimes 
in infections. 

If alcohol is used under these circumstances, it must be re- 
membered that frequently repeated doses will cause its ac- 
cumulation, when its sedative effects upon the nervous system 
will show themselves. A large dose is also counterindicated for 
the same reason. The so-called cardiac stimulation of alcohol 
is of short duration and not well maintained, either in those 
accustomed to its use or in others to whom it is given repeatedly 
in full doses. There are other medicaments capable of producing 
similar results, and that by constant repetition, do not produce 
sedation. When the effect of alcohol upon the heart has worn 
off, the latter beats less vigorously and more slowly than at first ; 
in other words, its stimulation of the heart is followed by a period 
of depression. The heart has been known to stop suddenly 
when a pint of whisky or more was drunk at once. This is 
probably due to strong reflex action produced by irritating the 
mouth, gullet, and stomach. From the fact that depression 
follows stimulation it is evident that alcohol does not act as a 
food to the heart muscle, but as a spur or stimulant. This 
stimulant effect is obtained only from small doses. Large ones 
directly depress and paralyze the heart. Very large ones cause 
it to dilate. 

The habitual use of alcohol makes the heart actually beat 
faster than is natural. For instance, according to B. W. 
Richardson, one ounce of alcohol daily will increase its beats 
430, two ounces 1872, four ounces 12,960, six ounces 30,670. 
This makes the heart do much more work than it does when 
alcohol is not taken. That a period of unnatural enfeeblement 
should follow its use is not, therefore, surprising, especially 
as it does not feed the heart. 

There is much discussion as to whether or not alcohol is 
a food. If a food is defined as anything that can be decomposed 
in the tissues and eliminated in a form different from that in 
which it enters, alcohol is a food. The inadequacy of this 



ALCOHOL A FOOD. 139 

definition is self-evident. Water is a most valuable food, yet 
it is not decomposed, but eliminated as ingested. Many- 
poisons are decomposed, at least in part, in the body, as most 
foods are. If food is denned as a body that contributes to the 
growth of cells or their multiplication, and to the generation 
of heat and energy by them, it is very questionable if alcohol 
can be classed as a food. When limited amounts, not exceeding 
one or one and a half ounces a day, are taken in small doses at 
a time, it seems to be decomposed by the tissues and does not 
appear in the exhalations from the lungs or skin or in the urine. 
This would suggest that it has a food value. Its effect upon 
heat and energy production will be referred to later. Ham- 
mond found that when he was upon an insufficient diet and was 
losing weight, the addition of a little alcohol made him gain. 
This also suggests its having a food value. The calorimetric 
experiment of Atwater points to its having a limited food 
value. For three days he measured the number of calories 
produced by a man on non-alcoholic diet in the calorimeter. 
For the next three days he made similar observations upon the 
man but substituted an isodynamic quantity of alcohol for 
an equivalent amount of carbohydrate and found the resultant 
in calories in both instances was the same within a small 
fraction of 1 per cent. But if alcohol is taken generously or in 
large quantities most of it escapes through the lungs, skin and 
kidneys without being utilized in the body. It is often, 
although not uniformly, noticed that habitual drinkers put on 
flesh. This does not, however, demonstrate that the alcohol 
has entered into the structure of cells in a beneficial way. It 
modifies oxidation processes, prevents the complete utilization 
of foods, and causes a retention of fats and some waste-products 
in the system. 

The fact that it can be proven that only a very limited quan- 
tity is retained and replaces or saves other components of 
food, is not characteristic of a true food, which if not used at 
once for the production of energy or cell growth is at least 
stored and in the process undergoes changes in composition. 
Moreover, food gives strength but alcoholics lessen it at least 
if more than small quantities are taken. They also interfere 



140 BEVERAGES. 

with or modify the normal function of organs and lead ulti- 
mately to destructive changes in many tissues. 

The fact that it does not appear in the excretions of the body 
when not more than one ounce is taken in a day hardly demon- 
strates its utility as food. The most recent researches point 
to its being a poison to protoplasm, but it is probable that 
this amount may be taken without noticeable impairment. 
Hutchison 1 says: ''Alcohol is a protoplasmic poison or anes- 
thetic, but is itself easily burnt up in the body." Because of 
this effect, he continues, " If alcohol gets access to the cell and 
partially paralyzes or anesthetizes it, the cell will lose its power 
of breaking down those compounds, such as fat, with which it 
has, even in a condition of full activity, most difficulty in 
coping. Alcohol then saves fat from combustion; in other 
words, it is a fat sparer. It also appears, though with greater 
difficulty, to be able to spare carbohydrate, but it is exceedingly 
doubtful whether it is ever able so far to paralyze the cell as to 
destroy its power of dealing with protein." It exerts much the 
same influence upon cells generally, interfering with or lessening 
their normal functions, that it does upon the red blood-cor- 
puscles with whose power to take up and set free oxygen it 
interferes. It does this by making with hemoglobin a com- 
pound that is an inefficient oxygen carrier. Is it not probable 
that it unites similarly with some cell constituents and modifies 
their functions? We know that when applied directly to cells 
it coagulates a part of their albumin, as has been explained of 
its topical action on mucous membranes. 

One ounce of alcohol should yield as much heat by combus- 
tion as one ounce of butter — about 200 calories. But prac- 
tically this is not the result. In 185 1, the late N. S. Davis first 
demonstrated that alcohol lowers temperature. Two factors 
help to cause this loss. Even small doses dilate the peripheral 
arterioles, bringing thereby a large amount of hot blood rapidly 
to the surface of the body, from which radiation quickly takes 
place. Therefore more rapid radiation of heat is one factor 
causing a lowered temperature when alcohols are drunk. 
Considerable doses also lessen oxidation or heat-production. 
The fact that bodily temperature is thus lowered has caused 

1 "Food and the Principles of Diet," page 344, London, 1911. 



EFFECTS OF ALCOHOL. 14 I 

those who send men into cold regions to forbid the use of 
alcohol, because it increases greatly their liability to freeze. 

Alcohol has been advised in fevers as an antipyretic. It has, 
however, the same mode of action and the same faults as other 
chemical antipyretics and is less efficient than several of them. 

Nor does alcohol increase muscular energy. Experiments 
with the ergograph and with the dynamometer, as well as the 
cruder ones that have been so frequently repeated, of having 
the same work done by two sets of men, alcohol being given to 
one set only — all demonstrate that more muscular work can be 
done without it than with it. After a dose of alcohol a man 
feels that he can lift a great weight, or in other ways exhibit 
unusual strength, and is surprised to find that he cannot. The 
subjective error is due to the same interference with the per- 
ceptive faculties that permits after-dinner trivialities to pass as 
weighty utterances. Fatigue is hastened, not delayed, by it. 

As alcohol does not modify protein metabolism, it will not 
materially change the output of urea. Experiments upon this 
point are conflicting. H. C. Wood, however, believes that it 
lessens the products of tissue waste. In fevers the albuminoids 
of the body suffer greatly and they are not proportionally, if 
at all, protected, by alcohol, as fats, and to a limited extent 
carbohydrates, are said to be. If alcohol is not taken in 
sufficient quantity to produce intoxication, only a very small 
percentage will escape from the body unchanged ; but if enough 
is taken to intoxicate, 10 per cent, or more may do so. 

Under the influence of full doses of alcohol the vessels of the 
brain, like those of the skin, become greatly relaxed and filled 
with blood. When this change is first produced, the mind 
seems invigorated. It is generally asserted that mental work 
is for a time more easily accomplished. This is doubtful. All 
parts of the brain are not affected with equal quickness or by 
the same doses. The brain-cells are poisoned or partly para- 
lyzed, the higher ones before the lower. The portion of the 
brain that is most influenced by external inhibitants or that itself 
restrains the other portions is first affected. So soon as the 
normal restraints are lessened, one becomes garrulous, ready to 
say and to do things that otherwise he would not do or say. 
The effects thus produced may easily deceive and lead one to 



142 BEVERAGES. 

think that the mind has been stimulated, when it has only been 
unchecked. It has been shown that continuous mental work 
of a high grade cannot be done as well with alcohol as without 
its influence. Activity of neurons may multiply the trains of 
association and quicken the succession of images, but the 
weakening of inhibition prevents concentrated choice. Thus 
judgment is affected early, while imagination may be left 
untrammeled. The emotions may be more than usually 
active. The drinker is easily made combative, affectionate, 
lachrymose. Moral perception is less keen in the habitual 
user of alcohol than in others. Mental diseases are often 
due to it. The motor centers are also easily involved, some- 
times even before judgment is materially affected. Speech 
is made thick, and later the movements of the extremities are 
unsteady or uncertain. Walking and other movements show 
imperfect muscular coordination. 

It requires very large doses of alcohol to affect the spinal 
cord. When it is involved, the respiratory center is paralyzed 
before the heart is. The vasomotor center is, however, early 
involved. The various portions of the central nervous system 
are affected in the same order as when ether is administered. 
They may all be overwhelmed, producing stupor or even death. 

Quantities of alcohol not sufficient at any one time to produce 
intoxication or outwardly visible effects will, if their drinking 
be habitually repeated, seriously injure the tissues by interfering 
with oxidation. The brain and nervous system are especially 
likely to feel the effects. Degenerative changes are excited in 
these structures. In these, as in all tissues, even if alcohol 
enters them only in small amounts yet is present constantly or 
with frequency, the chemical energy of the cells is diminished 
or changed. The disturbed metabolism leads to fibroid and 
later, to fatty metamorphosis. The disturbed metabolism of 
proteins increases or creates a tendency to attacks of gout 
or to the more chronic or obscure lithemic or alloxuremic dis- 
turbances. Sometimes the disturbing influence of alcohol upon 
carbodydrate decomposition and appropriation aids in the 
production of diabetes. 

Although it is claimed that alcohol when given in small doses, 
is not eliminated as such, it is well known that all inflamma- 



EFFECTS OF ALCOHOL. 143 

tions of the urinary organs are aggravated by it. Those who 
have been steady, moderate, or heavy drinkers are especially 
prone to renal diseases. Two or three glasses daily of a bever- 
age containing so small an amount of alcohol as is present in 
beer will cause casts to appear in the urine. The liver is also 
especially susceptible to disease when alcoholic drinks are used. 
The stronger beverages are most likely to affect it. 

Individuals vary greatly in their susceptibility to alcohol. 
Some show ill effects from small doses, and others are seemingly 
resistant to large ones. Certain persons are stimulated by it 
to eat more heartily and to do less, and as oxidation goes on 
more slowly in these persons, they easily accumulate fat. 
Although plump, they are not resistant to disease, nor capable 
of prolonged hard work. 

Because alcohol is an antiseptic it has been tried as an internal 
antiseptic in infectious diseases. Experiments have shown, 
however, that alcohol given to animals lessens their power to 
resist inoculation with numerous micro-organisms. When 
given in infectious diseases, no antiseptic influence has been 
demonstrable. 

Alcohol is unnecessary in health, and those who have not 
strong self-control or who inherit a love of liquor or a tendency to 
inebriety, to gout, to arteriosclerosis, or to other degenerative 
changes are better off without it. Many individuals can use it 
in strict moderation without apparent harm. The majority 
sooner or later find that even with moderation they are not so 
well when they use it habitually, and they cease to drink it, or 
they take it more rarely. The abuse of alcoholic beverages is 
invariably harmful. The wisdom or unwisdom of the use of 
alcoholic beverages in health is not a question that the physiolo- 
gist alone can determine. The ease with which the habit of 
using them grows to an excess and the injury done thereby to 
society make the desirability of their use a social problem as 
well as a physiologic one. This is not, however, the place to 
discuss the sociologic phase of the subject. 

There are drugs that may be substituted for alcohol which 
are equally potent with the latter for the treatment of the sick. 
Its use is, therefore, not necessary either in health or in sickness. 
When prescribed in disease, it must be regarded as a medicine 



144 BEVERAGES. 

and not as something to be used at will by the patient. As the 
percentage in all beverages varies greatly, it would seem best, 
as urged especially by B. W. Richardson and by the late N. S. 
Davis, to prescribe pure alcohol diluted to the desired strength. 
Doses can then be regulated with the certainty deemed nec- 
essary when other medicines are given. It must be rem- 
embered, when in the following pages percentages of alcohol 
in various beverages are mentioned, that they are averages, 
the variation in different samples often being considerable. 

Alcoholic Beverages 

Alcoholic beverages are generally classified as fermented or 
distilled. The former include wines and beers; the latter, spirits 
and liqueurs. 

Spirits are made by fermenting various saccharine substances 
until as much alcohol as possible has been generated in them. 
From the mixture of sugar, ferments, water, and alcohol the 
latter is distilled. When separated in this way alcohol can be 
made of various grades of strength and purity. The saccharine 
matters that are subjected to fermentation are derived com- 
monly from barley, corn, rice, potato, sugar, and molasses. 

The odor and flavor of each kind of spirit depend upon its 
source and upon different volatile ethers and by-products of 
fermentation that also pass through the still. Their medicinal 
action is that of alcohol. 

Whisky is defined by the United States Pharmacopeia as 
"an alcoholic liquid obtained by the distillation of the mash of 
fermented grain (usually mixtures of corn, wheat, and rye) and 
at least four years old." It has an alcoholic strength of from 
44 to 55 per cent, by volume. It should be free from disagree- 
able odors. Its specific gravity should be between 0.945 and 
0.924. When spirits of any kind are kept, the volatile ethers 
and aldehydes that give flavor and character to them change 
and become more agreeable. For this reason distilled liquors 
are always ripened for a variable period of time. 

Brandy of the standard of the United States Pharmacopeia is 
"obtained by distillation of the fermented, unmodified juice of 
fresh grapes, and should be at least four years old." Its specific 



ALCOHOLIC BEVERAGES. 145 

gravity varies from 0.941 to 0.925. It contains from 46 to 
55 per cent, by volume of alcohol. Brandy is kept for many 
years to ripen. 

Rum is distilled from fermented molasses. It is often made 
by adding molasses caramel and various essences or flavorings 
to a solution of rectified spirit. It contains about the same 
percentage of alcohol that whisky and brandy do. 

Gin is distilled from a rye mash. It is flavored by juniper 
berries, which are put in the mash during distillation. It con- 
tains from 15 to 20 per cent, of alcohol, but is often strengthened 
by the addition of proof spirit, so that it contains from 30 to 35 
per cent. Gin undergoes a double distillation and contains, 
therefore, less solid matter than the other forms of spirit. No 
gin contains so much as 1 per cent. There is no sugar in it and 
little acid. 

Liqueurs and bitters are made from pure alcohol and various 
spirits and wines by the addition of sugar, aromatic herbs, and 
essences. The following table, compiled by Hutchison, will 
afford some idea of the composition of a few of those most 
commonly used: 

A.COHO, EXTRACT £»» bSES- 

Absinthe 58.93 0.18 0.32 

Benedictine 52.00 36.00 32.57 3-43 

Creme de Menthe 48.00 28.28 27.63 0.65 

Anisette '. 42.00 34-82 34-44 0.38 

Chartreuse 43.18 36. n 34-37 1.76 

Beer or ale and stout or porter are made by fermenting malt 
and hops. Malt is made by germinating moistened barley at 
a uniformly moderate temperature. During germination the 
starch of the grain is converted into dextrin and sugar. Malt 
after it is dried and ground, is mixed with water to make a 
'mash,' which in turn is heated to different degrees by different 
brewers. In this way the starch is more completely trans- 
formed into sugars and the latter are carried into solution. 
The action of the diastase of malt is arrested by boiling the 
wort, or filtrate, of the mash. Hops are boiled with it in order 
to extract some tannin, a bitter principle, and extractives. 
After the wort has been boiled it is rapidly cooled, and finally 
10 



146 BEVERAGES. 

fermented by the addition of yeast. To obtain a uniform prod- 
uct great care is taken that only a pure culture of yeast is 
used, and accidental infection of wort by other ferments is 
guarded against. Most of the yeast gradually rises to the top 
and can be skimmed off; some settles to the bottom of the tank 
in which fermentation is carried on. The beer is drawn into 
casks, where fermentation to a limited extent continues. The 
yeast is finally completely precipitated, and the clear beer 
bottled. If it stands long in casks the slight fermentation that 
goes on gradually increases the percentage of alcohol in it, 
making a 'heavier' beer. 

Beer and ales are described as 'mild' or 'bitter,' accordingly 
as they contain relatively much or little hops. The tempera- 
ture at which malt is dried and mash is made also modifies the 
taste and character of the final product. Sugar and dextrins 
are important constituents of the fermented beverages. 

Stout or porter is made as beer is, but the malt used 
in its brewing is first roasted, by which process some 
caramel is formed in it. This gives to the final product a 
dark color. 

All these beverages contain from 3 to 8 per cent, of alcohol, 
from 1/2 of 1 to nearly 1 per cent, of sugar, from 2 to 5 per cent, 
of dextrins, and possess a demonstrable acidity. 

The acidity of beer will check starch digestion in the stomach. 
Its bitterness, however, increases the flow of saliva and the 
secretion of gastric juice. Beer delays the chemical process of 
gastric digestion more than the small amount of alcohol in it 
will account for. It increases and often creates abnormal 
acidity of the stomach, and flatulence. Beer and stout are 
especially likely to produce obesity. Their use predisposes the 
drinker to gout and lithemic affections. They cannot be used 
by diabetics because of the carbohydrates which they contain. 
They also aggravate renal inflammations, cystitis, and urethri- 
tis. They are frequently drunk in quantities sufficient to dis- 
tend the stomach even to a pathologic extent. Many persons 
feel somnolent after drinking beer, wherefore it is frequently 
taken at night as a mild soporific. 

Wine is fermented grape- juice. The quality of wine depends 
upon many conditions. Some of these are : the variety of grape 



WINE. 147 

used, the soil and climate in which it is grown, its culture, and 
the character of the ferment that is employed in the manufac- 
ture of the wine. In recent times bacteriology has solved 
many of the problems with which wine-makers were formerly 
struggling. Pure cultures of various yeasts are used, and 
sometimes combinations of them, in order to produce the 
flavors that are sought for in wines. The sugar in grape- juice 
is more or less completely decomposed by fermentation, pro- 
ducing thereby varying amounts of alcohol. Its more or less 
complete fermentation depends in part on the amount of 
albuminous matter in the grape-juice. The yeast lives upon 
the albumin, but during its growth breaks up the sugar. If a 
given grape-juice is rich in albuminous matter, all the sugar 
may be fermented, and a 'dry' or sour wine may be the result. 
If it contains little, the wine will be sweet. The character of 
wine is often modified by the addition of alcohol or sugar. 
Natural wine cannot contain more than from 15 to 16 per cent, 
of alcohol, as yeast-cells are paralyzed by it when this percent- 
age is reached. 'Fortifying' or adding alcohol to wine is a 
common practice. It is done both to flavor it and to prevent 
all further fermentation in it. Sherries are always fortified; 
so are most champagnes, especially the sweeter ones. 

The details of wine-making vary greatly and cannot be 
described here. The character of individual wines depends 
much upon the methods employed in their manufacture. 
Some are made from the juice squeezed from the grapes under 
high pressure; others are made by fermenting the juice with 
more or less of the skins and seeds in it. To some grapes, lime 
is added when they are crushed. So much to illustrate the 
very numerous modifications that are adopted by wine-makers 
in the production of this beverage. The most important 
ingredients of wine are water, alcohol, acids, sugar, ethers, 
extractives, and glycerin. 

Wine contains several alcohols. Ethyl is the one that occurs 
in the largest amount; amyl, propyl, butyl, and others are 
developed in it in smaller quantities. A wine containing more 
than 15 per cent, of alcohol is fortified. 

The most important of the vinous acids are tartaric and 
tannic. A number of others are sometimes present. Acetic 



148 



BEVERAGES. 



acid is not uncommon. The total amount of acid varies, but 
is often considerable. 

Sugar occurs in wine in too small a quantity to be of much 
value as a food. The sweet wines contain about 4 per cent, of 
sugar, and the sour ones 1/2 of 1 per cent., Or thereabouts. If 
wine were taken in sufficient quantity to obtain from it more 
than one-half or perhaps one-third of an ounce of sugar, it 
would produce intoxication. 

The ethers result from the action of alcohols and acids upon 
one another. The flavors of special kinds of wine depend 
largely on the character and relative percentage of the contained 
ethers. They are very numerous, but each one occurs in very 
small percentage in any given specimen of wine. The extrac- 
tives are mostly such carbohydrates as pectins and gums. 
Glycerin is always present in wine, but in very small proportion. 

The following table from Dupre's analyses will give some idea 
of the chemical composition of a few wines that may be regarded 
as types of larger groups : 



Wine 


Absolute 
Alcohol 


Total 
Acid 


Sugar 


Dry 
Residue 


Ash 


Total 
Alcohol 

in 
Ethers 


Hock, 

Claret, 

Hungarian, .... 

Greek, 

Sherry, ..... 

Madeira, 

Port, 

Marsala, 


9-73 

9.68 

10.16 

12.35 
17.80 

17.82 
18. 1 1 
16.80 


O.506 

0.599 
0.694 
O.611 
O.487 
O.680 

o.434 
O.361 


0.062 
0.243 
0.077 
0.225 

3015 
1.850 
2.540 
3-5O0 


I.92 
2.12 
I.90 
2.50 
5.06 
4.44 
5-34 
5-36 


0.17 
0.21 
0.18 
0.30 
0.50 

o.37 
0.23 
0.26 


O.042 
O.038 
0.046 
O.048 
O.061 
O.096 
0053 
O.049 



Cider, which is made from apples and pears, is very similar 
to wine. It contains from 3 to 8 per cent, of alcohol, from 0.2 
to 0.6 per cent, of sugar, and 0.1 to 0.6 per cent, of acid. The 
chief acid present is malic. 

Sparkling wines and ciders are bottled before fermentation is 
checked, and filled with carbonic acid gas by its continuance. 
When uncorked, the gas escapes in bubbles. This is called 
'natural sparkling.' Artificial sparkling is produced by forcing 
carbonic acid gas into wine, as into soda-water. Effervescence 



EFFECTS OF WINES. 149 

adds to the attractiveness of wine, modifies its taste, and is said 
to hasten the absorption of alcohol from the stomach. 

Wines check the chemical processes of digestion more than 
can be accounted for by the alcohol they contain. One per 
cent, of sherry will stop salivary, gastric, and pancreatic 
digestion. It is probable that the acids in wines, and possibly 
also some of the ethers, increase the inhibiting influence of 
alcohol over digestion. Sherry and port are more active in 
delaying digestion than claret, and much more so than cham- 
pagne. Although they exert this deleterious influence upon 
the chemical processes of digestion even when they are taken 
in small quantities, they often improve appetite and stimulate 
more vigorous gastric peristalsis. Large amounts lessen 
nervous and muscular excitability. 

A person leading a sedentary life cannot with safety take as 
much wine as one who is doing hard muscular work. Accepting 
as a just estimate the statement upon an earlier page that two 
ounces of alcohol is the limit permissible in health, one bottle of 
claret that contains approximately this amount is all that 
should be taken in a day, and not to exceed half of this amount 
of the stronger 'fortified' wines, such as sherry. Taking 
different kinds of alcoholic beverages at a time, or even during 
one day, interferes with digestion more than the drinking of 
one kind does. Wines are used in health chiefly because their 
flavor is agreeable and their milder effects upon the nervous 
system, such as lessening sensibility to worries and nervous 
tension, are grateful. 

Their habitual use often produces sour stomach. Sometimes 
their excessive use causes gastritis. When those who are dis- 
posed to lithemia, gout, or rheumatism drink wine habitually, 
and sometimes even when they drink it only occasionally, they 
become especially liable to outbreaks of these maladies. It is 
not probable that the alcohol in the wine is the only or the chief 
cause of this. The acids and the sugars in it must also be 
blamed. For although the organic acids form in the blood 
alkaline salts which theoretically should do good, especially in 
cases of uric acid calculi, it is probable that the presence of acid 
wines commingled with food, and especially with sugar and 
starch, delays digestion, and permits the occurrence in the con- 



150 BEVERAGES. 

tents of the stomach of changes that produce the chief toxic 
principles. The ill-effects of these beverages are usually not 
felt by persons of the class under consideration immediately 
after drinking, but in from twelve to forty-eight hours later. 

The tannic acid in sour wines gives them a rough, astringent 
taste. Such beverages may lessen diarrhea and aggravate 
constipation. 



CHAPTER X 

DIET IN HEALTH 

Diet for Athletes in training. Diet for Brain Workers. Starva- 
tion. Diet in the Different Periods of Life. 

It is self-evident that a larger amount of fuel or of calories — 
that is, units of energy — will be needed by those who are work- 
ing hard than by those who are doing but little physical work. 
The tables in Chapter V illustrate the differences in the amount 
of food consumed by different classes of workers because of 
the different demands that their systems make and that are 
expressed by their appetite. However, the appetite is not 
always a good guide to the amount of food or kind of food that 
should be eaten. It is often capricious. It is commonly 
governed by habit, and therefore does not quickly adjust itself 
to varying modes of life. For example, many men who have 
worked hard during early manhood and middle age, when they 
needed a large amount of food, continue to eat as heartily after 
they give up such work and begin to lead a life of leisure. At 
the end of the tables on pages 46 and 1 56 is given the estimated 
amount of food needed by those doing various kinds and 
degrees of work. 

Diet for Athletes in Training 

Much has been written of the diet best adapted to an athlete 
when training for a contest. The object of training is to prepare 
a man to do a very large amount of work, and sometimes 
skilled work, in a very short time. This is a different problem 
from that which confronts a laborer or an artisan. The latter 
requires that regimen which will enable him to do a large 
amount of work daily over long periods of time. During the 
period of preparation for an athletic contest, muscles must be 
made to grow, and the waste caused by tests or trials of strength 
be repaired. Proteins are therefore needed for cell growth and 

151 



152 DIET IN HEALTH. 

repair. They are also required, as has already been explained, 
to furnish nervous energy. 

The work that muscles do can be accomplished upon carbohy- 
drate food, as it will economically furnish a large number of 
calories or units of force. But to set the muscular work free 
quickly, and to perform it accurately by a correct correlation 
of movements, much nervous energy is needed, and for its 
production proteins are required. When large amounts of 
food must be eaten, proteins should form a conspicuous part 
ot the diet, because they are digested with comparative ease. 
Such carbohydrate food as is eaten should be as digestible as 
possible. 

In preparing for many kinds of athletic contests it is also an 
object to lessen the weight of the contestant as well as to increase 
his strength. This is best accomplished by exercise. A 
relatively large amount of protein will also help to accomplish 
it. However, athletes, when in training, always eat enough to 
grow fat, if it were not for the severe exercise that they take. 

Increased endurance is acquired by such exercises as gradually 
strengthen the heart and increase the depth and power of 
respiration. Diet influences these changes only as it does 
general strength, by furnishing to the muscles and the nerves 
to be used, such food as they need to produce energy. 

Experience has taught athletes and their trainers that a 
generous mixed diet is the best one for them. At the training 
tables of the Harvard and Yale crews such foods as the following 
are eaten: Breakfast cereals, dry toast, vegetables in reason- 
able variety, and fruits; beef, lamb, mutton, chicken, fish, 
bacon, and eggs. Desserts of simple puddings or ice-cream 
are furnished, but no highly seasoned food. 

The utility of sugar or of carbohydrates as producers of 
strength has already been dwelt upon. In this connection it 
is interesting to note the experience of the Holland oarsmen 
who, while in training, began to show signs of overwork, loss 
of flesh, a lack of ambition and energy, and disinclination for 
study. and work. By eating sugar as freely as they wished, 
sometimes as much as one-third of a pound a day, they were 
refreshed and enabled to win a race against antagonists who 
did not believe in its use. Sugar is generally permittedfto 



DIET FOR ATHLETES. 1 53 

those in training, but pie, cake, and other sweet and more or 
less indigestible dishes are forbidden. 

Although food must be eaten by those in training in larger 
amounts than by the same persons at other times, care must be 
taken not to overeat, and thereby derange digestion; nor must 
meals be eaten at too long intervals. 

The table on pages 156 and 157, compiled by At water and 
Bryant, gives a summary of results of dietary studies of uni- 
versity boat crews, foot-ball teams, and professional athletes, 
and compares them with the ordinary diets of men of various 
occupations and with the generally accepted standard dietaries. 
It is noticeable that the diets of the university crews compare 
closely with the American standard for one doing hard work 
and are somewhat more generous than that of German and 
English standards. The largest amount of food is eaten by 
the foot-ball teams. It is also noticeable that the proportion 
of proteins is greatly increased relatively to other kinds of food. 
This is also true of Sandow's diet. The excess of proteins in 
the food of college students training for a contest is particularly 
striking when their diet is compared with that of their fellows 
at an ordinary college club. The latter furnishes 3690 calories 
and contains 107 grams of protein; the average diet of a col- 
lege crew in training furnishes 4085 calories and contains 155 
grams of protein. The difference in fuel value of the two diets 
is approximately 400 calories. The oarsmen's diet furnished 
one-ninth more energy than that of their fellows who were not 
doing athletic work. There was a difference of 48 grams, or an 
increase of nearly one-half, of protein. The relative propor- 
tion of protein was therefore unusually large. 

Tea, coffee, and cocoa are usually permitted to men in train- 
ing. Occasionally the first two cause so much nervousness as 
to prevent skilful coordination of muscles and they must be 
forbidden. Spirits and other strong alcoholic beverages are 
forbidden. Beer and light wines are sometimes allowed. 

Violent exercise should not be taken soon after meals. It will 
hinder and sometimes stop digestion. Light exercise with 
dumb-bells or pulley weights is not only permissible, but de- 
sirable before breakfast, but prolonged or violent exercise 
should not be taken after so long a fast as a night's sleep entails. 



154 :DIET in health. 

If violent exercise is attempted after a hearty meal, it will be 
observed that weariness is felt more quickly, and that it requires 
more mental force to compel one's self to do the work, and even 
under such compulsion it is not done with the quickness, clever- 
ness, and accuracy that may be shown at other times. 

Although exercise creates a need of food to restore the 
strength and energy that has been expended, it is best not to 
eat immediately after exercise. A short rest of a half-hour or 
an hour should intervene. The habit of athletes of reclining 
and being rubbed for some minutes after exercise is useful 
both as a rest, and as an equalizer of the circulation. 

Diet for Brain -workers 

Mental work does not increase bodily waste. In this it 
differs radically from physical work. But it cannot be well 
done unless nutrition, and especially the nutrition of nervous 
tissues, is good. There is no kind of food especially adapted 
to create nervous energy or to restore worn nervous tissue to 
a condition of vigor. Agassiz at one time suggested that, as 
the brain was rich in phosphorus, a food containing it, such as 
fish, was best adapted to the needs of brain- workers. Exper- 
ience has demonstrated that this is not true. Intense mental 
work checks digestion just as all kinds of strong emotions do. 
It is evident, therefore, that health will not be preserved if the 
habit is formed of doing hard mental work immediately after 
eating heartily. It is quite as harmful to accomplish hard 
mental work immediately after a large meal as it is to do hard 
physical work. Indigestion and slow digestion always make 
mental work difficult; therefore the most important dietary 
regulation for those who must do hard mental work constantly 
is that the food eaten shall be easy to digest. In other words, 
the regimen must be determined by the digestibility of food 
rather than by its composition. Brain-workers need a com- 
paratively small amount of food. As proteins of animal origin 
are, as a rule, digested easily, and quickly and readily utilized 
by the living tissues, they are well adapted to the needs of such 
persons. There is a dependence of nervous activity upon 
muscular activity. While one is working hard, exhaustively, 
with his muscles, he is unable to do much mental work. One 



OVEREATING. 1 55 

who does prolonged and intense mental work will find his mind 
grow dull and his temper become quick, irritable, and peevish 
unless he maintains a balance between muscular and nervous 
work by some gentle exercise. It is probable that under these 
circumstances, exercise does good chiefly by stimulating a better 
lymph circulation through the brain as well as other viscera, 
and therefore a more rapid and perfect elimination of the 
products of tissue waste. 

Overeating 

Overeating is a common fault in adult life and not uncommon 
in childhood. With children it is usually an acute condition; 
with adults, a chronic one. Men and women are tempted to 
overeat by habits acquired early in life and by the pleasures of 
the table. When in good health, a moderate excess of food 
can be digested and comfortably utilized and eliminated, but 
more than this leads to pathologic states. If the excess of food 
is small and taken habitually, it may not disturb digestion, but 
will gradually lead to obesity or to a condition that borders 
upon grossness. The kidneys are particularly prone to be 
injured by high living, which means not only eating heartily, 
but also eating rich and highly seasoned foods. Chronic 
nephritis is the lesion most commonly produced under these 
conditions. Arteriosclerosis is also likely to develop. 

The eating of excessively large meals is a common cause of 
indigestion and of gastric dilatation. The liver is also frequently 
overtaxed and its functions disturbed. 

Starvation 

Abstinence from food can be persisted in for variable periods 
of time. If the faster is in a room where an equable and com- 
fortable temperature is maintained, and if he is supplied with 
all the water that he needs, and is permitted as much rest as he 
requires, life, and even health, can be maintained for six weeks 
and more. If, in fasting, much energy is consumed in main- 
taining body-temperature or in doing work, death will occur 
in a few days. Under favorable conditions life will be main- 
tained until even the half of the usual weight of the body is 
lost. 



SUMMARY OF RESULTS OF DIETARY STUDIES OF 

(Nutrients in food actually 



Proteids. (Quantities 


DIETARY STUDIES OF UNIVERSITY BOAT CREWS, 


20 


40 


60 


80 


100 


120 


140 


160 


180 


200 


220 


240 


























Harvard University crew at Cambridge (No. 227). 


162 












































Har vard Freshman, crew at Cambridge (No. 228). 


153 










































Yale University crew at New Haven xNo..229) 


145 












































Harvard University crew at Gales Ferry (No. 230_ 


160 










































Harvard Freshman crew at Gales Ferry (No. 231; 


135 








































Yale University crew at Gales Ferry (No. 232) 


171 












































Captain of Harvard Freshman crew (No. 233). __ 


155 
























* 




















Average . 


155 
























SUMMARIZED RESULTS QF OTHER. DIETARY STUDIES 


























Football team, college students, Connecticut . 


181 














































FootbaH team, college students, California 


270 
















































Professional athlete, Sandow . 


244 


















































Prize fighter, England 


278 


















































Average of 15 coHege clubs 


107 








































Average of 14 mechanics' families 


103 








































Average of 10 farmers' families* 


97 






































Average of 24 mechanics anad farmers 1 families 


100 






































Average of 14 professional men's families 


104 








































DIETARY SBANDARDS 




Man with moderate muscular wor-k,"Voit 


118 








































Man with moderate muscular work, Playfair 


119 






































Man with moderate muscular work:, Atwater I 


125 










































Man with hard muscular work, Voit 


145 












































Man with hard muscular work, Playfair 


156 












































Man with hard muscular work, Atwater 


150 












































Man with severe muscular work, Playfair 


185 
















































Man with severe muscular work, Atwater 


i 175 













































156 



UNIVERSITY BOAT GREWS AND OTHER DIETARY STUDIES, 
eaten per man per day 7) 



in Grams.) 


Fats 


Cart 

hyd 


y ", Calories. 

ates 


260 


280 


300 






450 


900 


1350 


1800 


2250 


2700 


3150 


3600 


4050 


4500 


4950 


5400 


5850 


6300 


6750 


7200 


7650 


8100 






















































175 


449 


4130 






























































223 


468 


4620 
































































170 


375 


3705 




























































170 


448 


4075 






























































152 


416 


3675 




























































171 


434 


4070 




























































181 


487 


4315 






























































177 


440 


4085 




































1 






















292 


557 


5740 1 
































































416 


710 


7885 










































































. 






151 


502 


4460 






























































78 


83 


2205 
























































148 


459 


3690 




























































150 


402 


3465 


























































130 


467 


3515 
























































141 


429 


3480 


























































125 


423 


3325 




























































.56 


500 


3055 
























































51 


531 


3140 




























































3500 


























































100 


450 


3370 


























































71 


568 


3630 
































































4500 






























































71 


568 


3750 
































































5700 



























































157 



158 DIET IN HEALTH. 

When tood is suddenly withheld, hunger increases until it 
becomes extreme. This feeling lasts for two or three days, 
when the desire for food gradually lessens. During the period 
of hunger there are burning and gnawing in the epigastrium, 
which are followed by a feeling of weakness and faintness. 
When food is gradually lessened, the feeling of hunger may not 
be experienced, or, if experienced, not in an extreme degree. 
The body loses weight at first because the fat of the adipose 
tissue is consumed, and later because the muscles waste. The 
heart grows quick and feeble. The temperature of the body falls 
so that it is subnormal much, if not all, of the time. Finally, 
muscular exertion may be impossible. The mind grows dull 
and listless. Dreams, hallucinations, and insomnia may tor- 
ment the starving person. The aspect of those who are starv- 
ing is pitiable in the extreme. We have become familiar with 
it because of the numerous pictures in illustrated papers of the 
famine sufferers in India. 

After prolonged starvation it is not well to administer food in 
generous quantities, or any food except what is most digestible, 
as the organs of digestion have become so weakened that they 
cannot do much work. At first, small quantities of bland, very 
digestible food, such as milk, gruel, or albumin water, should be 
given every half-hour until some improvement is evident. The 
amount of food may then be gradually increased and a larger 
variety given. 

Diet in the Different Periods of Life 

Aged persons bear want better than do young ones. Indeed, 
after middle life abstemious eating should be practised in order 
to maintain health. During old age less work is done; tissues 
cease to grow, and repair takes place slowly. The need for 
food is therefore greatly lessened. It is a common dietetic 
error at this time to eat too much. Food should be varied, but 
taken in small portions. When old people are feeble, they 
should eat four or five times daily. Often because of few and 
poor teeth old people must live chiefly upon liquid and soft 
foods. Whenever it is possible their teeth should be repaired or 
false ones provided that food of all kinds may be eaten. As 
tissue repair and tissue growth is stopped or reversed, a gradual 



DIET IN MIDDLE LIFE. 1 59 

wasting being the rule in old age, protein foods are not so neces- 
sary as in early life. Moreover, they are not so desirable, for 
often elimination of nitrogenous waste by the kidneys is less 
perfect. Bland, easily digested foods should be preferred. 
Foods which are not easily digested will ferment in the gastro- 
intestinal canal and will form toxic substances which increase 
arterial tension and thereby the work which the heart has to do. 
The latter organ under these conditions grows weak and is 
unable to maintain a perfect circulation, a condition which 
deranges the functions of various organs. This produces ill 
health and is often the cause of fatal illness. Such stimulating 
beverages as tea, coffee, and cocoa are well borne and particu- 
larly grateful. 

In middle life, or, to be more exact, after the thirtieth year, it 
should be remembered that it is no longer necessary to eat to 
make more tissues or to promote growth, but only to maintain 
an equilibrium of weight and strength. At this time the 
habit acquired in childhood of eating largely is strongly estab- 
lished and the pleasure of eating is most appreciated. Therefore, 
most men and women are inclined to eat too much and to eat 
food that is too rich or that, although most palatable, is indiges- 
tible. It is at this time that indiscretions of diet are with 
especial frequency a cause of disease. The quantity of food 
eaten should vary with the amount and character of one's 
physical work. When a sedentary life is led, only the most 
digestible foods should be eaten, and these in moderate 
amounts. 

At this time the habit of eating only what is needed should 
be acquired and earlier habits should be broken. The average 
man should limit himself to small portions and should make it 
his rule not to take more than one portion of any kind of food 
at a meal. This general rule is subject to modification for 
many who are doing hard physical work need a somewhat more 
generous supply than this general rule implies but they should 
endeavor to vary their eating as their work varies. It is a 
common observation of physicians that farmers who eat very 
heartily during the summer when their hard work enables them 
to digest and utilize it continue the same habit during the 
winter when work is comparatively light. This results at first 



l6o DIET IN HEALTH. 

in mild forms of indigestion, but ultimately in a chronic gastric 
disorder. 

In infancy and childhood food must be eaten to maintain 
heat, which is radiated with relatively great rapidity, to supply 
muscular energy, which in childhood is generously expended; 
and to supply the great demands that rapid growth of tissues 
makes during the earliest years of life. The most rapid growth 
takes place in infancy, when there is the smallest expenditure of 
muscular energy. The composition of mother's milk, which is 
nature's especial aliment for this period, gives us a key to the 
kinds of food needed and to the relative quantity of each 
required to promote a rapid growth of tissues. It contains 
from i to 2 per cent, of protein, approximately 4 per cent, of 
fat, 5 or 6 per cent, of digestible carbohydrates, and about^oo 
per cent, of water. Food of this composition does not make 
hard, firm flesh or create power to resist disease. These condi- 
tions are developed later when the diet is richer in proteins and 
solids. 

From the following table compiled from the more extensive 
one made by E. A. Locke, 1 it will be easy to estimate the pro- 
tein and caloric value of a meal made up of common foods for 
the values are given for portions ordinarily served. 

^ood Values by E. A. Locke, A. M., M. D. Published by D. Appleton & Co., N. Y., 191 1 



FOOD VALUES. 



161 



O H 

n < 

•< Q 

x 








£ < 




2 2 




£o 







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< 


2 * 
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fri 




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a 




s 




o 


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« Oi -t oo o o\ Tt o\ « 



N M Ci M fO 



M O O O vo M O 



-* O t- -* 



O O c* •* O Oi f} ^- O <0 



mmtI-O^^-Omon 



00 O O O O vO O 
00 O (0 >o O W h 



w W « ei N N 



O N \<D 0\ W iO M 



«o o o «fl m 

m o o t^ t^ 



o o o o o o o 

O O O t- O H o 



w c 

4) .5 

c co o 

3 4) •- 

O ^3 w 



oOooOoooo 

coOcoc/lOcOCOtac/] 



3 a a ^a 3 

"33 "3 *a> <u "a; 
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4> D a; co a) 
bo bo bo bo bo 



> > > 
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m or 



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q co 



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l62 



DIET IN HEALTH. 



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tr, 


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n 




































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9 a 






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^ oo 


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O SO 


V) -<t CO 


O Tt 


O CO O O w O 


w 


r- >o 


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vO 


o\ 1- ■<*■ 


■<t «o 


t^ H IH 


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a a o oo o o 


o 




O M 


00 


co oo oo 


» w 


«!/>*■» 


t O 


lO <0 M CO O O 


<* 



<t O v>aooco m * O oooo 

Tt-O»^«O>00^-Mt^t»MH 



f0« Tf «*)«*) t*3 <*) *0 « ■>* *0 O O «) (<) m ^ to* »^«>o o» 



o o o o o 



iOir>i/>«/iOOmOOOOO 



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23 


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td 


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60 




c 








a 



S .3 ■£ .£ 

n - o 'o 



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aaaaaaaaaaa : « o o o 

3 3 3 3 3 3 S 3 3 S S-nSSS 
ooooooooouo'S'Shhh 



o y. en OT W 

s •- ^s ^s ^ 

o "w "S "5b "Si 



•ti 

01 

•sl 

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St* 

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2 m % 

- .£> rt 
& fi °. 

« S g 

a ib § S E 
S, c .* .3 g 

8 » .s .a o 



s & 

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B 3 












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tit Ah /« 



bo 

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B "2 

n »h uj 
S .P £ 



<3 ^ 






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w o 



FOOD VALUES. 



163 



m 
W 
P 

< 
> 

P 

O 

o 

o 
s 

c 
o 



2 H 



2 w 

H 3 

S2 



£0 



W5 Ov «/> 00 



0\ « r» O* CO 



to o co o m a 00 



H ^ OJ «♦> M »-» M « M *i 



« 


O O 


O 


O O 


O M 


H 


6 


CO 


M O) 


CI 


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co O 


4 








a 


O 


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M ' 
















































1000 


CO w 


O 


to 00 


O O 







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Tf 





\r> 


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00 t» >t 


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10 


10 00 


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*t 


LT> 


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r~ 


t^ *0 CO 




00 


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ro 


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O M 


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n 





l»> 


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ro 


co 


f*> « M 


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n 


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H 


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c c 

o o 

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(jffltlOJUDIUU 



00 00 

a a 
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60 +i 

5 w 

a 5 



c c c c 
0000 
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x> x 3 .a 



*» N N N 



. w 

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■ JS 
: 3 

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a 
c 
c 
c 
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at 


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«<U(D<Utt)a)«J(UH(U 

CO"fr«NC»COCOMCOC« 






"w '55 bo 60 00 60 '53 

C C g c C C d 

5 5 'a "a 'a "a E 
.2 .2 oj a «j a .2 

Tl n-l OJ U 0) fl) tI 
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S S 



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c S 



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164 



DIET IN HEALTH. 



Ov 00 VO WJ 
N CN O 



cnoono»omo*<) 



wi O <3\ O 10 



5 * 



O f> o o 



IO <N O <-> 



Ov Oi Q\ *0 o 



00 o 00 w Tt 



O «1 (1 N O 

o o 



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O O M o 



O O O O to 



M S 



C*mOOmOOOOOm 



tOHOOfOOOOOOOOcOPOtO 



£0 



o a 00 o 



M 

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X .fj 



© fl> « *». tw 

00 M 00 c C 



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to > 



c a a c c 
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Pi Pi P i O r Pi 

to to to to to 

]) g> OJ O 1) 

3 3 3 3 3 



bo 00 bo 00 bfl 

S 5 S 2 H 
'a "a 'a 'a "S. 

MHWHfONHMP) 



3 3 
*r o o 

to 3 3 



•8 c 



o o 



Id <8 <U 

a a m 
a oi o 

h h O 

000 



to >2 
<U X 

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ffi O PL. 



•3 

<u 

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a 

a 

eg 

CD 

TO C 
<D .S 
Oh PU 



'£ G is - 

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pMp4c/3^<!QfcPM 



1 

to 

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is a 

cd a 



1« 



tu .. >> 

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£ T3 
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2 o 



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<D X 

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xi a 

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pq PQ 



FOOD VALUES. 



165 



r*t/)r»^-M it n ■<* \o «- 



M C3\ 



to w « * 



N to N to 



00 


00 





10 


\n vo 


to 


IO 


CO 










Ov 


w 


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00 


t^ 


M 


M 


10 


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t^ 





vO 


O 










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to 


s 





>* 



M o o o o 



13 



D r» t^ O O ■* 00 



O O O 00 & r» O* 



N e» to C\ M O M 



• • •; *; g ^ w ti .a .2 .2 : 

• -^^^n^^^^^co 



h p <s a q c c 



c c 


c c a a c c a 





0000000 





0000000 


a a 


Qi Q, O, O. Q, O. O. 




tO CO CO CO CO 10 CO 

(D 4) O 43 CD CD 4) 








X X 


Xi Si X> X X XI XI 


rt nj 








60 00 


bo 60 bo bo bo to bo 


c c 


c c a c c c 






a a 


a a a a a a a 


aj 0} 








si si 


.a si si si xi x xi 


V, T? 


<M to N CI CI IO M 



X 
O ra 

- J£ x 

w "3 -a, 
•3 £~ 



co .3 

1 St 



£5* 



CO 



2^ 



O £ 



6 J2 



N O 4) 

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o a. 






xf. 

5 9 

rt co 

w C 
bo C 



p 2 o o 



Si <u 



4) g 

2* c 
O (J 



4 '■ * 

H fl fl tri 

. *g 2 ffi 5 ^2 

ffi £ 2 a o£ ^ 



i66 



DIET IN HEALTH. 



J M 

o o 

H i 



a o « noo no ») 

O to u> ^CO «*)^-« 



6? 

3* 

a 



« i« *0 ■«* M tooooo 



M K) M «$- 



1 

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CO 

p 
> 

Q 

o 

£ 

o 

o 
o 



83 



io * io m no io>o 



S3 M 



jj v v o> 4> 

'a "a "S 'a 'a 



« <o « « « 



'!"S c 

atifi 
o. 3 o 






^ e 






a a 

3 S 



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3 <o 



5 3 5a o-^ £ 



ea 

so 

g-g 

a 

s 

° 3 



15 



2 o> 



ll 



FOOD VALUES. 



167 



2 5 



5 3 

* as 



8 3 



60 . 

S w 

a? 

8,9 

CO 



c« -^ 

& 60 

a I & & 

o rt rt S 

_.. a> a> S 



o 
'3 

s 

B 

- ^ 
g-B 

a 



« J 



60 "O 



£ rt 

,9 o 

to 
H 



.2S 

a 60 

■»-> 03 



S 8 & .2 

o o t( w a g, 

S" S* « a * 3 

3 S «• .§ a S 

60 rt d " « 6 3 

4) *J *> .2 §, CO O 

•h *0 « 9* G O M 
rt i_i 

H 



8 s 
§8 

a a 



-4-> 0) 

rt 60 
* S 

"afi 

3 1 



i68 



DIET IN HEALTH. 



o 



X 






mo a 

M O 6 



.§1 

» o 

T3 ,« 



•s s s 

M w fo 
2 » C 



w 8. 



S.2 

8 2 
u bo 

«u g 



a i 

TG CO 

el a> 



10 10 

00 O :G G o o ^ 

j§o M 



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2g 

8 q. 



2 g VI) « ^ 



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c 
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& « 

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O . 

•£ 60 

v-i 00 

O 0) 






FOOD VALUES. 



169 



to 

J a 

is 

O 


r- 00 k - ,B (i * ^ 1 0"%*r^0 O tz+» • N 

H C> M Tf HI CI ,V W CI r»5 


CO 

■ W 
O H 
O < 

« a 

< Q 

O > 

X 




10 0000000000»/50>>© 
O r»»OON<NC«^-t^O»i-i»OOU'> 

« M 00 M 


» 5 


« 

0\ 
00 










«5 00 to O «) iO>0 *0 
NOMCIIOt-COO 

OOONr-NOOOUt^ 


2 » 
« s 















«oO O <fC W O «j 
m >0 Oi m M co f» 

tOO«MM>orot* 


« 2 


h m t«.\OONOvr>00^000« 
M N >iwOw>oiOCO>-'cOfO** 


Quantity 


c 

c 

c 

a 

I 


i 

c 

1 




c 
p 

£ 

c 


c 
c 

3 

a 

J 

\ 

t 


c 

c 

- c 

I 

c b 
c 

- '2 

r 
c 


) 
- a 


I 

s 

c 


s 

C £ 
C 


" 

I 






i 

c 


c 


g 

S 

1 c 


t 

1 c 
t- 

C 





to 
(t, 
Pd 

H 

w 

Q 

O 
O 

£ 


\ 

u 

c 
c 


Ingredients: 
4 tablespoons olive oil 
1 tablespoon vinegar 
1/4 teaspoon salt 
Pepper. 
Mavonnaise dressing 


Ingredients: 
2 eggs 

2 cups olive oil 
1 tablespoon vinegar or 
1 tablespoon lemon juice 
Salt, pepper, mustard. 
Cube sugar 


t 

" 
O 
C 

i 

c 

q 


1- 

S 
1 

O 

d 

c 

a 


1 

S 
= 

a 

1 

1 


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■ 
a 
c 

a! 

s 


to 

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c 
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c 

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PQ 


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5 



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l 
a 
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1 


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1 

s 
p 

V 


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5 

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1 

a 
Ph 


a 
s 

C 

■5 





170 



DIET IN HEALTH. 



I 

••a 

8 

<3 
I 

W 
P 

< 
> 

Q 

o 
o 

o 

o 
o 



(0 

►J 2 
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r- vt 0> 
M w N 


CO 

A w 
£ H 

9 * 

< 

> 

X 


«/} «<1 O 
00 00 W) 

t<> r» o> 

« M « 


58 


««> ** W 

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M M 


B CO 

is 


00 
00 

a « to 

H 




1^. VO O 
« « « 


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a 


C 


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c 


1 

1- 


1 


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fa 
fa 
t> 

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CO 

a 






03 ^ 

£& 

00 
3 

O CO 

00 5 
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a a c 

•- 4> CO ^ C 

w -^ +* ^ ° 

1 .S .5 a w i 
*a a a. 3 <" w 
<o rt rt c 

a ^ "^ \ ^ £ 

HH M H tO M Jt 

c 


S 

at 

2 

M ° n . 

•2 C 0} c8 

w fi n ** 

e °- w fc 

1 &JS « S 


I 

CO 

CO <u 

3 w 
S to 6 

1 i&i 

J 13 00 rt XI 

£ M 2 ^. eS 

. & »*^- 

» a H H ,0 M 



CHAPTER XI 

INFANT FEEDING 

Mother's Milk. Irregularity in Feeding. Rules for Infant 
Feeding. 

Mother's Milk 

Mother's milk is the food best adapted to the needs of infants 
and there is no perfect substitute for it. Not every mother. 
however, has enough milk for her child, or milk of a quality 
that adapts it to the child's needs. It is, therefore, necessary 
to study somewhat in detail the subject of human lactation and 
the effect upon infants of variation in the composition of milk, 
before taking up the subject of substitutes for human milk. 

From 700 to 2000 c.c. (27 to 65 ounces) of milk are secreted 
daily by a mother's breasts. The latter is an unusually large 
amount. The average child requires during the first weeks of 
life from 250 to 500 c.c. (8 to 16 ounces) of milk, and in the 
tenth, eleventh, and twelfth months from 1000 to 1500 c.c. (30 
to 50 ounces). 

The milk secreted by a mother's breast during the first three 
days after childbirth is called colostrum. It differs radically 
from that which is formed later. It is slightly laxative. The 
composition of colostrum has not been definitely determined, 
but a sufficient number of chemical analyses have been made, 
however, to show that it varies much. It is usually poor in fat. 
This causes it to look bluer than other milk. Under the micro- 
scope it appears, like milk, to be a fine emulsion of fat, but it 
also contains large cells called colostrum cells. They gradually 
disappear during the second week of lactation and rarely 
reappear. If they do, they indicate a disturbance of lactation, 
and the milk containing them is especially likely to disagree 
with the suckling. 

Mother's milk, like cow's milk, varies somewhat in composi- 
tion during the act of nursing. The 'fore-milk,' or that which 
is obtained at the beginning of the process of milking, is richest 

171 



172 INFANT FEEDING. 

in fat and contains less water. The variation in fat is not due 
altogether to the greater dilution of the 'fore-milk,' for the 
increase in fat in 'strippings' over 'fore-milk' may be more 
than 100 per cent., while the difference in fluidity is relatively 
slight. During the first week of lactation, milk is usually 
richer in proteins and poorer in fat and sugar than it is later. 
During the next week or two, the sugar reaches its normal 
percentage. Fat gradually increases and reaches its equili- 
brium during the second month. The percentage of protein 
falls simultaneously with the increase of fat. 

Analyses made for Dr. Effa V. Davis 1 of milk furnished from 
eight mothers on the fourth day of the puerperium averaged: 

Water Ash Protein Fat Sugar 

89.78 .36 1.98 1.20 6.54 

The protein varied between 1.21 per cent, and 2.67; fat 
between .20 and 2.40; and sugar between 3.58 and 8.25. Analy- 
ses made of the milk from five women drawn on the fourteenth 
day averaged: 

Water Ash Protein Fat Sugar 

89.70 .37 1. 71 1.58 6.83 

The protein varied between 1.47 and 2.65; the fat between 
.20 and 4.00; and the sugar between 2.74 and 8.86 per cent. 
Analyses made for Holt gave the following averages: 

Water Ash Protein Fat Sugar 

Fourth day 89.78 .36 1.98 1.20 6.54 

Fourteenth day 89.50 .39 1.71 1.58 6.83 

So long as lactation is normal the milk will vary little until the 
last months of nursing, when the percentage of proteins and fats 
decreases, although the total quantity of milk secreted increases. 

Conditions Affecting the Mother 

Is the character of milk modified materially by outside condi- 
tions that influence the mother? There is great diversity of 
opinion upon this subject. Two writers make such contra- 
dictory statements as the following: "Age has little influence. 
Illness, menstruation, pregnancy, fever, and even severe emo- 
tional disturbances are almost entirely devoid of any appreci- 
able effect on the composition of the milk" (Hutchison). 

1 Jul. American Medical Association, 1910, Oct. 10, 1212. 






CONDITIONS INFLUENCING MILK FORMATION. 1 73 

"Women are especially sensitive, and when living in the midst 
of our modern civilization, so harmful for the production of 
good nursing, present an aggravated example of disturbance 
of the mammary glands" (Rotch). Both of these statements 
are probably correct. It is true that some, probably many, 
women near the menopause suckle their babes successfully, as 
may also those suffering for the necessities of life and those 
who are under severe nervous strain or who have severe or 
chronic illness; but not all women can do so under such condi- 
tions. Measuring the quality of the milk by the results of the 
nursing as manifested by the growth of children, the milk of 
these mothers must be called good. On page 70 will be found 
a series of analyses of human milk made for Rotch, which show 
the wide variation of its composition. Upon each of these kinds 
of milk healthy children were reared. It is quite possible, 
therefore, for some infants to thrive upon poor milk that 
would be harmful to others, or would, at least, be deficient. 
It is also quite true that for weak babes, and especially for 
those who are under the physician's constant watch, milk that 
deviates much from certain standards of composition is sure 
to provoke illness. 

To a limited extent the quantity of a mother's milk can be 
increased by administering to her more water than she habitu- 
ally drinks. It can be reduced by withholding water and by 
withdrawing serum from the blood — as, for instance, by purga- 
tion or by acute enteritis. Drugs, such as belladonna, have 
a similar effect by lessening the activity of the mammary glands. 

The eating of carbohydrate and fat by mothers does not 
modify their milk. An abundant consumption of proteins, 
however, increases the percentage of fat in it. This is the only 
ingredient of milk that can be influenced by diet. Tea, coffee, 
cocoa, and beer, wine, and other alcoholics have no influence 
upon the secretion of milk, except as the water in them may 
increase the quantity, if sufficient be taken. 

If an infant is put to the breast too often, it stimulates the 
secretion of milk and renders it richer in protein. The practice 
followed by many mothers of giving the breast to their babes 
whenever they cry is wrong. As such crying is generally caused 
by colic resulting from an excess of protein in the milk, and as 



174 INFANT FEEDING. 

the practice referred to increases still more the protein contents 
of their milk and lessens its digestibility, it is evident that 
under such circumstances the infants should be nursed less 
frequently rather than with increased frequency. The protein 
contained in milk can be lessened to some extent if a mother 
will exercise daily to the point of moderate weariness. The 
average wet-nurse or mother should walk out-of-doors for one 
or two hours a day, preferably half the time in the morning and 
half in the afternoon. This will mean walking, all told, a 
distance of from three to four miles a day. It is probable that 
the weakness of the mother and the consequent lack of exercise 
accounts for the excess of protein in mother's milk and the 
period of colic that so many babes have during the second and 
third months of life. Wet-nurses often find their milk affected 
unfavorably, the result, no doubt, of a change from a life of 
labor to one of relative luxury and comparative inactivity. 

Menstruation does not always change the character of a 
woman's milk. During the first, and sometimes also during 
the second, menstruations after childbirth a slight digestive 
disorder lasting two or three days may occur. After this, the 
infant feels the disturbance little or not at all. In other in- 
stances indigestion is excited each month for a few days during 
the mother's menstrual period. In rare cases the reestablish- 
ment of menstruation so modifies the mother's milk as to make 
it necessary to use some substitute more stable in composition. 

Pregnancy of a mother is usually regarded as a reason for wean- 
ing a nursling, and rightly so, for few women have the strength 
to nurse a baby and develop a fetus at the same time. More- 
over, lactation cannot be maintained continuously. A period 
of rest must be obtained to insure the ability to suckle the 
coming infant. The constant irritation of the mammary glands 
by nursing has occasionally been thought to produce abortion. 

The influence of diet and exercise upon the secretion of the 
mammary glands has led Rotch to formulate the following rules : 

To increase the total quantity of milk: (a) Increase propor- 
tionately the amount of liquids in the mother's diet; and (b) 
encourage her to believe that she can nurse her infant. 

To decrease the total quantity : Decrease proportionately the 
amount of liquids in the mother's diet. 









EFFECTS OF VARIATION IN MILK. 1 75 

To increase the total solids: (a) Shorten the nursing in- 
tervals; (b) decrease the mother's exercise; (c) decrease the 
proportion of liquids in her diet. 

To decrease the total solids: (a) Prolong the nursing in- 
tervals; (b) increase the mother's exercise; (c) increase the 
proportion of liquids in her diet. 

To increase the fat : Increase the proportion of meat in her 
diet. 

To decrease the fat : Decrease the proportion of meat. 

To decrease the proteins : Increase exercise up to the limit of 
fatigue. 

Effects on Infants of Variation in Mother's Milk 

It is natural to ask next how the variation in the composi- 
tion of milk affects a nursling injuriously. When its food con- 
tains insufficient protein, the infant's flesh becomes soft and 
flabby, its skin pale, its power of resisting disease is lessened, and 
its liability to acquire rickets is greater. All this may happen 
and the child continue to be plump. When its food contains too 
much protein, particles of milk-curd will be seen in the stools, 
the infant will have colic, the stools will contain mucus, be- 
come numerous, soft, and finally thin. The temperature of an 
infant often rises when enteritis is fully established as a result of 
indigestion. An illness thus provoked may become severe or 
chronic. During the first two or three months of life more than 
1 to 2 per cent, of protein is not well tolerated by the average 
child. After this, protein can be taken in gradually increasing 
percentage. Some infants will take comfortably 4 per cent, of 
albumin after the first month ; some others of them will digest 
it even in their sixth month, although it is more than is found 
in human milk. 

If the milk is not rich enough in fat, the infant will lose flesh 
and gradually become rickety. Too much fat has a tendency 
to provoke diarrhea and vomiting. More than 6.5 per cent. 
is rarely well borne. Carbohydrates, except the amount of sugar 
of milk in that food, are not needed during infancy, as there is 
little muscular exertion required and fat seems to supply the 
needed heat better. Carbohydrates are said to be able to pro- 
tect tissues from waste, and therefore to lessen the need of 



176 INFANT FEEDING. 

protein food. This is true only of adult tissues. Carbohydrates 
do not lessen the need of proteins for children during the period 
of most rapid growth, when they are required to make new cells. 
An ability to digest starch does not ordinarily develop until 
several months after birth. Occasionally, however, an infant is 
seen who apparently utilizes such food from the earliest weeks of 
its life. It is found, as a rule, that starch and most forms of 
carbohydrate are inclined to ferment, to become acid in the 
child's stomach and intestines, and consequently to produce colic 
and diarrhea. For these reasons carbohydrates are not in- 
dicated as a considerable element of an infant's diet. Milk- 
sugar is the natural and consequently the best form of it for 
use at this time. It is the least likely to ferment, and is easy 
of digestion and absorption. From 5 to 6 per cent, is needed 
during the first two months of life, and about 7 until the tenth 
month, when a lower percentage can be given, and often a little 
starch can be added. More than from 7 to 7.5 per cent, is not 
tolerated by the average infant. 

It is evident that a knowledge of the composition of mother's 
milk often is essential in order to understand the causes of 
children's illnesses, and to determine what modification of diet 
is necessary to cure them. A clinical method of analyzing milk 
is required. An accurate determination of its contents can be 
made only by elaborate chemical analysis. Resort to this is 
sometimes necessary in order to determine the exact percent- 
ages of fat and protein in it. The proportion of milk-sugar and 
inorganic matter is almost invariable. By determining the 
percentage of fat and the specific gravity in a sample of milk 
it is possible to say what the relative amount of protein in it 
is. Holt directs that the milk for analysis be taken in the 
middle of nursing — in other words, that neither the ' fore-milk ' 
nor 'strippings' be used. From fifteen to twenty cubic centi- 
meters of milk are needed. Its specific gravity should be ac- 
curately determined by a small hydrometer. Ten cubic centi- 
meters should then be placed in a finely graduated cylindric 
test-tube. The latter should be stoppered and kept for twenty- 
four hours at approximately 70 F. During this time the 
cream will form a well defined ring at the top. It is well known 
that cream bears to the total fat in milk a ratio of 3 to 5. It 



EFFECT OF IRREGULARITY IN FEEDING. 1 77 

is, therefore, easy to determine the percentage of fat in the 
milk when we know the amount of cream in it and this ratio. 
The amount of fat can be much more accurately and quickly 
determined by the centrifuge. This method is used in dairies. 
The Babcock milk-tester is a cheap centrifuge devised for this 
purpose. The milk is placed in small flasks with long, gradu- 
ated necks. Equal parts of milk and commercial sulphuric 
acid are put into the flasks. The acid transforms the proteins, 
casein, and fibrin into soluble acid albumin that offers little 
resistance to the rising of the fat globules. The filled flasks 
are whirled in the centrifuge with a velocity of from 700 to 
800 revolutions a minute. The fat rises quickly in the neck of 
the flask, which is so graduated that the percentage of fat can 
be read at once. 

The relative proportion of proteins is determined when the 
percentages of fat and specific gravity are known, because if 
the proteins remain unaltered and the percentage of fat is low, 
the specific gravity will be high; but if high, the specific gravity 
will be low. If the fat remains unaltered and the proteins are 
high, the specific gravity will be high, but if the percentage is 
low, the specific gravity will be low. Therefore: 

1. If the percentage of fat is from 8 to 10 (high) and the 
specific gravity from 1033 to 1034 (high), it may be assumed 
that the percentage of proteins is high. 

2. If the percentage of fat is from 2 to 4 (low) and the spe- 
cific gravity from 1033 to 1034 (high), it may be assumed that 
the proteins are about normal. 

3. If the percentage of fat is from 8 to 10 and the specific 
gravity low, the proteins may be assumed to be low. 

4. If the percentage in fat is low and the specific gravity 
low, the percentage of proteins must be low. 

Irregularity in Feeding 

Irregularity in feeding, too frequent nursing, and too long 
intervals between nursing often make what has been good milk 
unfit for use. Mothers should not nurse their children so often 
as to make their milk too rich in proteins, or neglect them so 
as to impair their nutrition and to give them a food that is too 
dilute. Infants are so readily made creatures of habit that, 
12 



i 7 8 



INFANT FEEDING. 



if they are well, they will show signs of hunger only after the 
accustomed intervals. In order to preserve the mother's health 
it is best to habituate the infant to but one meal between ten 
o'clock at night and seven in the morning. The following table, 
modified from Holt's, will give the best intervals between feed- 
ings, the number of feedings a day, and the amount that the 
average child takes at each feeding: 



Age 


Number 
of Feed- 
ings a 
Day 


Intervals 

Between 

Meals 


Number 
op Night 
Feedings 


Quantities por 
One Feeding 




Grams 


Ounces 


First week 


io 

IO 

9 

8 

7 
6 

5 


2 hours 
2 hours 
2 hours 

2 J hours 

3 hours 
3 hours 
3§ hours 


i or 2 

i 
i 
i 
i 

O 
O 


30-45 

45-9° 

75-110 

90-140 

120—170 

160-240 

220—290 


i*-3 

2^-3! 

3-4 i 

4-5 i 

5-8 

7 1-9 


Second and third weeks . 
Fourth and fifth weeks . . 
Sixth to twelfth week. . . 

Third to fifth month 

Fifth to ninth month .... 
Ninth to twelfth month. 



The stomach of an infant is small and weak. It possesses 
little muscular activity and milk flows rapidly from it into the 
intestine and is digested there. During the later months of 
infancy the organ becomes more of a pouch and acquires more 
functional power. It is disputed whether or not during the 
first weeks of life milk clots in the stomach. It has been deter- 
mined that during the second or third months of life two- 
thirds of a meal will have passed from the stomach in three 
hours, and that in a half-hour more the organ will have been 
completely emptied. 

It is interesting to compare the ratio of food constituents in 
the diet of an infant six months old with that of an adult : 

The child's weight is to a woman's approximately as 1 is to 10 

The protein in the child's food is to that in the woman's 

approximately as 1 is to 8 

The fat in the child's food is to that in the woman's approxi- 
mately as 1 is to 1.8 

The carbohydrate in the child's food is to that in the 

woman's approximately as 1 is to 8 

The calories in the child's food is to that in the woman's 

approximately as 1 is to 5 



INFANT FEEDING. 



179 



When these statements are examined, one is struck with the 
relatively numerous calories generated by the infant's food. 
Much of this energy is needed to maintain bodily temperature. 
It must be remembered that the child's small body exposes to 
the air relatively to an adult's three times as much surface 
from which heat can radiate. About one-fifth of the energy 
that a mother's food will generate is given to her infant. It 
is evident that much of this heat is generated by fat. The 
infant consumes more than half as much fat as an adult. Its 
food contains also relatively a large amount of proteins and 
carbohydrates. It is, in other words, most generous in all 
ingredients, but especially so in fats. 

If ' fore-milk ' is examined bacteriologically, it will usually be 
found to contain a few bacteria. They are not found later un- 
less the mammary gland is diseased. It is evident, however, 
that micro-organisms do find their way a short distance into 
the lacteals, and that they are quickly washed out when the 
milk begins to flow. The micro-organisms most frequently 
found in human milk are those that commonly cause purulent 
inflammations — the streptococci and staphylococci. Thorough 
cleanliness of nipples and of clothing over them greatly reduces 
the number of these organisms. The mother's nipples should 
be washed frequently with a bland and slightly antiseptic solu- 
tion, such as one of boric acid. Care should be exercised also 
to have only the cleanest clothing over the breasts. 



Rules for Infant Feeding 

The rules for a nursing mother or a wet-nurse should be regu- 
larity of life, freedom from anxiety, worry, or excitement, a 
generous diet of easily digested and simply prepared foods, and 
abundant, gentle, but not excessive exercise. During the first 
few days after childbirth only liquid foods, such as milk, weak 
tea, broth, and gruel should be given. After the first three 
or four days soft foods of various kinds may be eaten. At the 
end of ten days two meals of the most digestible solid food are 
allowable. Gradually the mother may return to a normal diet. 
Liquids, either liquid food or water, should be taken generously, 
at first to encourage lactation and later to maintain it. No 
advantage is derived from the excessive use of tea, beer, or 



l8o INFANT FEEDING. 

other beverages; on the contrary, the mother's digestion is 
deranged by them and harm is done. During the first weeks 
of lactation there is more danger of over-feeding a mother than 
of underfeeding her. So soon as she can, she should be en- 
couraged to sit up, to walk, and to take other gentle exercise 
proportioned to her strength. To furnish suitable food to her 
child, a mother must be willing to modify her life so as to meet 
the requirements of good lactation. 

Rotch says that "mothers who are unhappy, who are un- 
willing to nurse their infants, who are hurried in the details of 
their life, who are irregular in their periods of rest and in their 
eating and exercise, are unfit to act as the source of food-supply 
to their infants." Mothers suffering from chronic diseases or 
from maladies that are communicable to their offspring should 
not nurse them. It often happens that mothers who would 
gladly suckle their children have no milk at all or only a little 
during the first few weeks after childbirth. For all these rea- 
sons, and sometimes because of a mother's death, certain infants 
cannot have their natural food. Under these circumstances a 
wet-nurse, if a good one can be had, is to be preferred. She 
should have a baby of approximately the same age as the one 
which she is to nurse. She should be perfectly healthy, strong, 
and even-tempered. Especially should no suspicion of tuber- 
culosis, syphilis, or other communicable disease attach to her. 
She should be willing so to eat, to exercise, and to live as to fit her 
best for the care of the infant. Unfortunately, as the parents 
are so completely dependent upon a wet-nurse for their child's 
welfare, she is likely to become tyrannical, lazy, and shiftless 
and thereby unfits herself for her duties. Because of the danger 
of transmitting hidden disease to a nursling and because of the 
frequent annoyance arising from the temper and habits of 
many wet-nurses, and sometimes out of compassion for the 
child that would be displaced at the mother's breast, parents 
often prefer to take the somewhat greater risk of rearing their 
offspring upon substitutes for human milk. 



CHAPTER XII 
INFANT FEEDING (Continued) 

Substitutes for Mother's Milk. Peptonization of Milk. Food 
for Premature Infants. Mixed Feeding. Weaning. Diet for 
Children. 

Substitutes for Mother's Milk 

There is no perfect substitute for human milk. On page 69 
the composition of the milk of several animals is compared 
with that of woman. None approaches the latter closely. 
Cow's milk is the best substitute for human milk, because it 
is abundant, cheap, and easy to procure. After the first three 
or four months many infants can digest it comfortably and 
thrive upon it. Others cannot take it unmodified until they 
are a year or more old. 

It is necessary to study with care the difference in compo- 
sition and character of cow's milk and of human milk. They 
differ chemically, as the following analysis shows : 

Human Milk Cow's Milk 

Per Cent. Per Cent. 

Water 87 to 88 87 to 88 

Protein 1 to 2 3 to 4 

Fat 3 to 4 3 1/2 to 41/2 

Sugar 6 to 7 4 to 5 

Mineral matter o . 1 to o . 2 0.7 

Reaction Alkaline. Acid. 

Cow's milk contains much more protein and mineral matter 
than does human milk, a little more fat, and less sugar. It is 
acid, not alkaline, in reaction. Cow's milk and human milk 
differ also in the character of the proteins. It has been 
estimated that one-eleventh of what is commonly estimated 
as protein in human milk is extractive matter, the exact 
nature of which is unknown. The proportion of casein to albu- 
min in human milk is approximately as 1 is to 2. In cow's 

181 



182 INFANT FEEDING. 

milk casein is to albumin as 6 is to i. The casein of cow's 
milk makes, with acid, large masses of cheese, which are dis- 
solved with difficulty by an excess of acid ; that of human milk 
forms a fine, loose, small, flocculent mass that is readily soluble 
in an excess of acid. The denser larger masses of casein obtained 
from cow's milk are due to the larger proportion of casein in it, 
and to the relatively smaller percentage of fat and soluble 
albumin, which acts mechanically to make a looser clot, and 
to the fact that cow's milk contains six times as much lime and 
three times as much acid as human milk. The fat of human 
milk contains more oleic acid, is in a finer state of emulsion, and 
is more digestible than that of cow's milk. The mineral matter 
of the two kinds of milk is different, but not to such an extent 
that this difference becomes of great importance. 

The density and size of the curds of casein in cow's milk are 
lessened by diluting it before acid is added. If cow's milk is 
diluted with five parts of water, acetic acid will produce no 
curd perceptible to the unaided eye. The reaction is similar 
in all respects to that obtained by adding the acid to undiluted 
human milk. If smaller proportions of water are added to 
cow's milk, perceptible curds will form when acetic acid is mixed 
with it, but these grow smaller and looser in proportion to the 
quantity of water added to the milk. Such dilution makes 
the protein much more digestible, but it also lessens the per- 
centage of all nutritive ingredients in the milk mixture. For 
instance, cow's milk that contains on the average 4 per cent, of 
fat, 4.5 of sugar, and 4 of protein will, if diluted with five 
parts of water, contain less than 1 per cent, of each of these 
ingredients. Even equal parts of cow's milk and water will 
lower the percentage of fat and sugar below that of average 
human milk, and leave in the mixture twice as much protein 
as is desirable. 

But the experience of pediatricians has shown that the pro- 
teins of cow's milk are not as universally indigestible as was 
formerly supposed. Indeed they are often well digested by 
feeble infants who on the other hand cannot digest fats. 

The average infant, however, needs milk modified by dilu- 
tion, by the addition of milk sugar and fat in the form of cream. 
Many years ago John Forsyth Meigs, of Philadelphia, found 



PERCENTAGE OF MODIFICATION. 1 83 

that milk diluted with water and strengthened with cream and 
sugar agreed more frequently with delicate infants than any- 
thing else. An analysis of the mixture thus empirically used 
showed that he had hit upon a combination of fat, sugar, and 
protein that resembled closely that of human milk. His son, 
Arthur V. Meigs, published a paper calling attention to these 
facts and to the errors in analyses of milk then currently 
accepted, and laid the foundation of the scientific modifica- 
tion of milk for infants' use. Twenty years ago Rotch urged 
that physicians think of all milk mixtures in percentages 
of their proximate principles. This is of the greatest utility, 
as it leads one to compare constantly the given mixture with 
average human milk, and when any ingredient is increased or 
lessened in amount, it is so changed with reason — that is, to alter 
the percentage of fat, or of protein, or of sugar. Nothing 
has contributed more to save infants' lives during recent years 
than furnishing them with clean, pure cow's milk, and its 
percentage modification. Various formulas have been devised 
by means of which percentage modification can readily be made 
by mixing cream, skimmed milk, milk-sugar, and water. In 
many of the larger cities of this country milk laboratories have 
been established, where milk, modified according to any pre- 
scription, can be procured, and where the modification is made 
by chemists, with as much accuracy as a prescription for medi- 
cine would be compounded by a pharmacist. In these labora- 
tories milk is sold that is obtained from herds of healthy cows. 
Both animals and milk are handled with the greatest care, to 
insure the cleanliness and purity of the latter. By a centri- 
fuge, cream is separated from the milk, which contains uni- 
formly a given percentage of fat. With this cream, milk, mik- 
sugar, lime-water, and distilled water the prescriptions for milk 
mixtures are filled. Some physicians, however, prefer 'gravity 
cream,' and so specify in prescriptions. 

The prescriptions should specify the percentage of fat, sugar, 
protein, mineral matter, and degree of alkalinity desired in the 
mixture. At the laboratories the milk will be Pasteurized if 
it is desired. As soon as a given milk mixture is prepared, so 
much is poured into a nursing-bottle as is needed for one feed- 
ing, and as many bottles are filled to this extent as the infant 



1 84 INFANT FEEDING. 

for whom it is intended will need during twenty-four hours. The 
flasks are plugged tightly with nonabsorbent cotton and put 
into a refrigerator. As many bottles are delivered daily at 
the home of the infant as are needed. When one is required 
for use, it is taken from the ice-chest, warmed sufficiently, the 
cotton plug is removed, and a rubber nipple fitted to it. In 
this way a minimum handling of the milk is insured, and when 
it is handled and changed from receptacle to receptacle, it is 
done by those who are trained to the work, and where every 
possible precaution is taken to insure cleanliness. All recep- 
tacles used for milk at the farm and in the laboratory, and the 
nursing-bottles as well, are perfectly sterilized in large ovens 
before they are used. The results that are obtained from the 
use of milk thus modified and thus carefully guarded against 
contamination, are naturally much better and more uniform 
than are gotten by older methods, or by methods that fail to 
insure equally rigorous supervision. 

At the instigation of Rotch, elaborate tables have been pre- 
pared by George E. Gordon and J. H. Waterhouse, by means of 
which the amounts of cream, skimmed milk, and sugars needed 
to furnish all kinds of percentage combinations of the proximate 
principles of milk can be determined at a glance. 

The percentage of each ingredient should be modified to suit 
the needs of children suffering from digestive disorders, and to 
suit the needs of healthy, growing children. It is surprising 
what a transformation can be wrought in a suffering child by 
properly adapting its food to its digestive capacity. In most 
cases too high a percentage of protein has produced indigestion. 
Sometimes too little fat and sugar have caused malnutrition ; or 
'infants' foods' rich in starch and cane-sugar have not been 
digested, have fermented in the child's stomach or intestine, 
and have produced illness. A milk mixture made of pure 
ingredients and uniform at all times in its composition fre- 
quency restores such children to health as if by magic. While 
pure milk and percentage modification of milk are the two 
great needs of most infants who must be reared upon a bottle, 
a few are found who will do better upon other preparations. 

Rotch advises the following percentage modifications of milk 
according to the varying age of the child : 



PERCENTAGE MODIEICATION OF MILK. 



I8 5 



Fat 

1st week 2.0 

2nd week 2.5 

3rd week 3.0 

4 to 6 weeks 3.5 

6 to 8 weeks 3.5 

2 to 5 months ... 4.0 
4 to 8 months ... 4.0 

8 to 9 months ... 4.0 

9 to 10 months . . 4.0 

10 to 10 J months 4.0 
10$ to 11 months 4.0 

11 to n£ months unmodified cow's milk. 



Sugar 


Protein 


Mineral 
Matter 


5-0 


0-75 


At least 0.15 


6.0 


1 .00 


At least 0.15 


6.0 


1 . 00 


At least 0.15 


6-5 


1 .00 


At least 0.15 


6.5 


1-5° 


At least 0.15 


7.0 


1 -So 


At least 0.15 


7.0 


2 . 00 


At least 0.15 


7.0 


2.50 


At least 0.15 


7.0 


3.00 


At least 0.15 


5.0 


3-25 


At least 0.15 


4.5 


3.5o 


At least 0.15 



Reaction 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 
Slightly alkaline 



More than the required amount of mineral matter is found in 
the cream and milk that is ordinarily used. The percentage 
mixtures are made slightly alkaline by using lime-water in 
part to dilute the milk. Sometimes it is necessary to change 
the percentage of protein more slowly than is indicated in the 
foregoing table. A tew infants will be affected by a sudden 
change of 1/2 of 1 per cent., and adapt themselves to it slowly. 
The changes may have to be made by sixths or quarters of 1 
per cent. 

A percentage modification may be made at home as well as in 
the laboratory. If, however, it is left to nurse-maids or to 
mothers who do not appreciate the need of accuracy and 
absolute cleanliness, results as good as are obtained from milk 
procured at milk laboratories cannot be expected. 

When milk modification must be made at home, the greatest 
pains should be taken to procure pure, fresh milk of uniform 
composition. (See p. 73.) As soon as it is received, it should 
be put into a two-quart fruit-jar to which the top should be 
fastened tightly. The full jar must be kept for the next six 
hours constantly at a temperature of approximately 35 F. 
At the end of this time the cream will be at the top of the jar. 
If the upper fourth is now separated from the rest, the needed 
cream and skimmed milk will be had. This separation is best 
accomplished by siphoning off twenty-four ounces, or three- 
fourths, from the bottom of the jar. The upper fourth, amount- 
ing to eight ounces, is left in it. Then the following table of 



i86 



INFANT FEEDING. 



Rotch's will enable any intelligent and trustworthy person to 
prepare the needed mixtures : 







Percentages 






Oi 


NCES 


Measures 1 


Fat 


Sugar Protein 


Lime- 
water 


Cream 


Milk 


Lime- 
water 


Distilled 
water 


Milk- 
sugar 


I.O 


5-o 0.75 


5 


2 


2 




15 


2 


2 


o 


5-o 0.75 


5 


4 







is 


2 


2 


o 


5-5 i-oo 


5 


4 


i4 




13* 


al 


2 


5 


6 . o i • oo 


5 


5 







14 


2* 


3 


5 


6.5 i-50 


5 


7 


1 




11 


2* 


4 


o 


7-o 1.50 


5 


8 







11 


2| 


4 


o 


7.0 2.00 


5 


8 


2* 




8* 


2* 


4 


o 


7.0 2.50 


5 


8 


5 




6 


2l 


4 


o 


7-0 3- 00 


5 


8 


7* 




3f 


2 


4 


o 


5-0 3- 00 


5 


8 


7* 




3 


I 


4 


o 


5-o 3.25 


5 


8 


8 




3 


I 


4 


o 


4-5 3-So 


5 


8 


12 








O 



These proportions give twenty ounces of each mixture. 
Enough should be prepared to last twenty-four hours. It 
should be divided into as many feeding-bottles as there are 
feedings to be given. These should be stoppered with aseptic 
cotton, and placed into a clean refrigerator. One bottle should 
be taken at a time, as it is needed. The greatest care must be 
exercised to insure cleanliness of the bottles. When one is 
emptied, it should be rinsed immediately. Later it should be 
sterilized by boiling in water. It should be allowed to drip and 
to dry with its mouth downward in a clean room. 

To find the necessary amounts of cream, milk, water, and 
milk-sugar to furnish any given percentage of each in a milk 
mixture, Baurer recommends the use of the following formu- 
las ; in them Q means the total quantity of modified milk needed 
for twenty-four hours; F means the percentage of fat; S, the 
percentage of sugar; P, the percentage of protein; C, the amount 
of cream required; M, the amount of milk; W, the amount of 
water; S', the amount of milk-sugar. To find the amount of 
cream needed the following formula must be employed: 

2x(F-P)=C. 

To satisfy this formula, cream that contains 16 per cent, of fat 
must be used. This is the percentage richness of gravity 
cream. If cream containing 12 per cent, of fat is used, Q must 

1 The measure for sugar holds 33/8 drams. 



PERCENTAGE MODIFICATION. 1 87 

be divided by 8 instead of by 12. To find the amount of milk 
needed, this formula must be used: 

4 

To find the amount of water needed, this formula must be 
employed : 

Q-(C + M)=W. 
To find the amount of dry milk-sugar, this formula is needed : 

(S-P)XQ _ S , 
100 

To illustrate the working of these formulas, let us suppose 

that we desired twenty ounces of modified milk containing 4 

per cent, of fat, 6 per cent, of sugar, and 1 per cent, of protein. 

If we substitute these figures in the first formula, we will have: 

20 

— X (4 — 1) = 5 of cream. 

Substituting in the second, third, and fourth formulas, we get: 

20X1 , .„ 

5 = of milk. 

4 ° 
20 — (54-0) = 15 of water. 

(6-1) X 20 

- = i of sugar. 

100 & 

Thus we find that five ounces of cream, no milk, fifteen 
ounces of distilled water, and one ounce of sugar will give 
twenty ounces of modified milk of the desired composition. 

Starting with the belief that in practice it is unnecessary 
that the percentage of fat should ever be more than twice that 
of the protein, Holt has found it easy to construct a table by 
which a series of formulas can be obtained in which the fat may 
be as high as twice the protein, and as low as only a little more 
than one-fourth the protein, with all the variations between 
these extreme limits. The first step is to secure milks which 
contain different fat percentages: 7 per cent, of fat, 6 per cent., 
5, 4, 3, 2, and 1 per cent. How this is done from one quart bottle 
of milk which has 4 per cent, of fat, and one which has 5 per 
cent, of fat is shown in the following table: 

1 ounce milk-sugar by weight in 20-ounce mixture adds 5 per cent. 
1 ounce milk-sugar by volume in 20-ounce mixture adds about 3 per 

cent. 
1 even tablespoonful in 20-ounce mixture adds 1.75 per cent. 



1 88 INFANT FEEDING. 

Every ounce of 7 per cent, milk in a 20-ounce mixture will 
add 1/20 of 7 per cent., or .35 per cent, of fat; every ounce of 
6 per cent, milk will add .30 fat. Every ounce of 5 per cent, 
milk will add .25 fat, etc. Every ounce of each of these milks 
will also carry with it .175 per cent, of protein and .225 of sugar. 
In the case of a young infant for whom .70 per cent, of protein 
is proper, 4 ounces of milk in 20 ounces of food will be required. 
If this 4 ounces is of 7 per cent, milk the food will have 1.40 
per cent, of fat; if it is 6 per cent, milk, the food will have 1.20 
fat ; if 5 per cent. 1 .00, etc. To raise both the fat and the protein 
proportionally the next increase would be to use 5 ounces of 7 
per cent, milk in 20 ounces of food; later 6 ounces in 20; 7 
ounces in 20, etc., etc. 

To raise the protein above .70 but without increasing the 
fat, this can be done by using 1 ounce more of milk in 20, but of 
the series containing the next lower fat; e.g., 5 ounces of 6 per 
cent.; 6 ounces of 5 per cent.; 7 ounces of 4 per cent., and 9 
ounces of 3 per cent., all give approximately the same fat while 
the protein is raised successively from .70 to .85, 1.05, 1.20 and 
1.60 per cent. In calculating the sugar percentage it is neces- 
sary only to see how much must be added to that already in the 
milk to bring it up to the percentage desired, remembering that; 

From 4 Per Cent. Milk From 5 Per Cent. Milk 

To obtain 7 per cent, milk use upper 16 oz upper 20 oz. 

To obtain 6 per cent, milk use upper 20 oz upper 24 oz. 

To obtain 5 per cent, milk use upper 24 oz all. 

To obtain 4 per cent, milk use all remainder after skimming off 2 oz. 
To obtain 3 per cent, milk use remainder after skimming off 2 oz., 

remainder after skimming off 3 oz. 
To obtain 2 per cent, milk use remainder after skimming off 4 oz., 

remainder after skimming off 5 oz. 
To obtain 1 per cent, milk use remainder after skimming off 8 oz., 

remainder after skimming off 8 oz. 

When more than 20 ounces of food is to be made up one should 
add for 25 ounces one-quarter more of each ingredient; for 30 
ounces one-half more; for 40 ounces twice as much, etc. In 
order to calculate the caloric value of the food quickly it is only 
necessary to note the number of ounces of the milk used in the 
formula, multiply this by the caloric value of 1 ounce, and add 
the caloric value of the sugar or barley used in the formula. 



MODIFICATION OF MILK. 1 89 

According to Koenig's analysis, the proteins in cow's milk are 
casein, 2.88 per cent., and whey proteins, 0.53 per cent.; in 
human milk they are 0.59 and 1.25 per cent, respectively. It 
is evident from this how large a relative percentage of casein, 
which is the least easily digested of these proteins, there must 
be even in low percentage modifications of cow's milk. To 
make modified milk resemble human milk still more closely, it 
has been proposed to use the richest cream obtainable by 
the centrifuge, and to dilute this with whey instead of milk. 
Thus it is entirely possible to make a modified milk of nearly the 
same chemical character as human milk. Although 3 2 per cent, 
cream is needed with which to make the most nearly perfect 
imitations of human milk, yet with whey instead of milk used 
as a diluent, even with creams of lower percentage, a mixture 
can be made that is more digestible than the ordinary forms of 
modified milk. As yet formulas have not been devised whereby 
this can readily be done at h'ome. The milk laboratories, how- 
ever, furnish the combinations upon prescription. Hammar- 
sten says that cream 200 parts and whey 800 parts, or cream 
100 parts, milk 100 parts, and whey 800 parts, will make a mix- 
ture that contains the normal proportion of proteins to human 
milk. Ashby makes a 'humanized milk' of 10 ounces of fresh 
milk, 20 ounces of whey, and half an ounce of milk-sugar. The 
composition of this mixture is fat 2.5 per cent., sugar 6 per cent, 
and proteins 1.75 per cent. This is a low percentage of fat. If 
16 per cent, cream, or gravity cream with the approximate 
composition stated in our table, is diluted one-fourth by the 
addition of three parts of whey, the following composition will 
result : 

Fat Sugar Casein ^**Z u 
100 parts of 16 per cent, cream will 

contain 16. 4.5 2.8 0.5 

25 parts, or one-fourth of this, will 

contain 4. 1.12 0.7 0.12 

75 parts of whey will contain 0.24 0.36 0.0 0.63 

100 parts of the mixture will contain 4.24 1.48 0.7 0.75 

This is a mixture approximating human milk in chemical 
composition, except that it requires the addition of milk-sugar 
(4.52 parts) sufficient to make six parts in 100. 



190 INFANT FEEDING. 

By remembering the percentage composition of cream, and 
knowing that whey contains on the average 0.86 per cent, 
protein, 0.32 per cent, fat, 0.49 per cent, sugar, 0.65 salts, and 
93-38 water (Koenig's analysis 1 ), one can calculate the amount 
of cream and whey needed to give definite percentages of fat 
and protein to a mixture. 

Whey is best prepared by coagulating with liquid rennet a 
milk from which the cream has been removed as perfectly as 
possible. The milk and rennet should be kept at approxi- 
mately 30 C. (86° F.) until the curd is formed. The latter 
must be filtered off through clean muslin or absorbent cotton. 
The filtrate must be quickly heated to 65 C. (say 92 F.) to 
destroy the rennet. If raised to 70 C. or over (say ioo° F.) 
the whey proteins will also be precipitated. 

The experiments of White and Ladd demonstrated that 
cream and whey mixtures contain as perfect an emulsion of fat 
as is found in natural milk. 

As yet percentage modifications made with cream and whey 
have not been sufficiently used to make it possible to say what 
will be the practical results of feeding children upon them. 

Freeman says that cream contains 300 times as many bac- 
teria as the lower strata of a bottle of milk and Hess has shown 
the upper two ounces of cream in a bottle of milk contains the 
vast majority of streptococci, tubercle bacilli and other bacteria. 
The abundance of microbes in cream is one of the dangers 
incident to its use in infant feeding but a danger not generally 
avoidable. 

Many babies need food containing a low percentage of fat as 
others need a low percentage of protein. Too much fat pro- 
duces so-called "fat-diarrhea." Milk must often in these cases 
be stopped altogether for a few days, albumin water or barley 
water being substituted. Later skim milk or buttermilk 
must be given. A persistent intolerance of food with a high 
or even normal percentage of fat is a peculiarity of some 
infants. Without doubt the high percentage of micro-organ- 
isms in milk rich in fat as well as sometimes the inability of 
individual infants to digest fat well is the cause of the illnesses 
which such milk provokes in these babies. The same illnesses 

1 Agricultural Department analysis makes average proteins i per cent. 



PEPTONIZED MILK. 191 

are moreover found in breast-fed babies and due to the same 
causes. The necessity of adapting milk to the individual needs 
of infants as regards both protein and fat must be kept in mind. 
Moreover, when milk mixtures rich in water are fed it must 
not be forgotten that babies also require the usual mineral 
ingredients of mother's milk and these must often be added to 
milk mixtures. 

Peptonization of Milk 

Partial peptonization of milk is useful in the early weeks of 
infancy, and when the functions of the stomach are weakened by 
illness. It is necessary for all children to take full cow's milk 
at some time, and it should be given to them as soon as they 
can digest it, unless they are being fed at the breast. But 
when digestion is not perfect, peptonization of milk is a help. 
By peptonization, milk is partly digested so that its complete 
digestion is easier for an infant. The commonest digestive 
used for the preparation of babies' food is Fairchild's pepto- 
genic milk powder. Each powder contains enough ferment to 
digest a certain quantity of milk, some sodium bicarbonate to 
make it alkaline, and enough milk-sugar to give the milk mix- 
ture the proper percentage of that ingredient. When the 
directions given with the powders are closely followed, there is 
obtained a mixture having a specific gravity of 1032 and with 
the following percentage of ingredients: 

Water 86.00 

Protein 2 . 09 

Fat 4.38 

Sugar 7.26 

Mineral matter 0.26 

When a child's digestion is very greatly enfeebled, it may be 
necessary to peptonize even modified percentage milk for the 
time being. This can be done by adding pancreatin and sodium 
bicarbonate to the milk mixture. 

Condensed Milk 

Of the three forms of condensed milk, (1) unsweetened whole 
milk condensed, (2) sweetened whole milk condensed, and (3) 
sweetened skimmed milk condensed, the first is the only one 
that should be used. When water is added to it in proper 



192 INFANT FEEDING. 

proportions, it will resemble whole cow's milk. To make it 
resemble human milk, cream and milk-sugar must be added to 
it just as to ordinary milk. If either of the other kinds of con- 
densed milk is used, it must be so greatly diluted to reduce its 
sugar percentage to a proper one, that it will contain a very 
small percentage of fat. For instance, if one of the second 
group of condensed milks is diluted as the directions with it 
advise for infants' use, it will average less than 1 per cent, of 
fat. If the third group is used, the percentage of fat given 
to the baby will be still less. 

The presence of cane-sugar in the last two groups of con- 
densed milk makes them liable to ferment and to excite gastro- 
intestinal trouble. On the other hand, its absence in the first 
lessens the keeping power of the milk after the can is opened. 

Condensed milk is not necessarily sterile, although by con- 
densation it is made to keep well for long periods. It is con- 
densed at too low a temperature to sterilize it. Pathogenic 
micro-organisms are not always destroyed during its manu- 
facture, but may lie dormant in it or grow with slowness. 

Babies fed upon condensed milk often look plump because of 
the abundance of sugar in their diet, but they are likely to be 
pale, flabby, and to lack power to resist disease. Frequently 
a malady resembling scurvy develops in those fed exclusively 
upon such milk. This can be partly counteracted by feeding 
orange- and grape-juice to such babies. 

In the process of condensation some change is wrought in the 
milk that makes it more digestible than fresh cow's milk. This 
probably accounts for its agreeing with many delicate children 
when fresh cow's milk will not. According to my experience, 
percentage milk can always be made to agree with such infants 
as well as condensed milk, and usually better. It is not advis- 
able to use the latter except when fresh cow's milk or human 
milk cannot be had. 

Proprietary Foods 

The number of proprietary foods for infants is great. They 
are open to the same objections that have been raised to con- 
densed milk. They are deficient in fats, contain an excess of 
sugar, and often insoluble starch. Some of them are useful 



PROPRIETARY FOODS. 1 93 

after teething, when the employment of farinaceous foods is 
begun. The following analyses, made for Hutchison, will show 
the composition (per cent.) of several foods well known in the 
American market: 



Food Wate 

Dried human milk 

Horlick's malted milk. . . 3 

Carnrick's soluble food ... 5 

Nestle's milk food 5 

Mellin's food 6 

Ridge's food 7 

Robinson's groats ...:... 10 

Robinson's patent barley 10 







Carbo- 


Mineral 


Protein 


Fat 


hydrate 


Matter 


12.2 


26.4 


S2.4 


2.1 


i3-8 


3.0 


76.8 


2.7 


i3-6 


2-5 


76.2 


2 . 2 


1 1 . 


4.8 


77-4 


i-3 


7-9 


trace 


82.0 


3-8 


9.2 


1 .0 


81.2 


0.7 


n-3 


1.6 


75o 


i-7 


5-i 


3-9 


82 .0 


1.9 



Horlick's food is a desiccated milk with wheat flour and 
barley malt added. Carnrick's contains, besides desiccated 
milk, malted wheat flour and milk-sugar. Nestle's contains, in 
addition to desiccated milk, baked wheat flour and cane-sugar. 
Mellin's food is a desiccated malt extract. It must be added 
to diluted milk for infant feeding. The other preparations 
should be used only when it is entirely safe to employ farina- 
ceous foods. (On p. 112 the composition of other farinaceous 
foods is given.) 

No food is so uniformly good for infants as mother's milk. 
The best substitutes are cow's milk or percentage cow's milk, 
and peptonized milk for the very young and weak. 

Barley-water is often used as a diluent for milk because 
when the casein in the mixture curdles, a small, loose curd is 
formed. It is prepared by boiling five ounces of granulated 
barley in a quart of water until the volume is reduced to a pint, 
when it is strained; it is then ready for use. It contains very 
little starch or other nutritive matter. 

In the tenth or eleventh month of life farinaceous food may be 
added to the diet of the bottle-fed infant. Often it can be 
begun earlier without harm. It should not be given, however, 
until after the teeth have cut through the gums. As a rule, it 
should not be begun much earlier than the eleventh month, 
since the amylolytic functions are not fully established before 
this time. Some children can use starches earlier without 
apparent harm, but the average infant cannot do so. One of 
13 



194 INFANT FEEDING. 

the best preparations to begin with is oat jelly. This is prepared 
by soaking four ounces of coarse oatmeal in a quart of cold 
water for twelve hours. The mixture is then boiled down to one 
pint, strained, and allowed to cool, when it forms a jelly. The 
latter may be thinned with milk so that it may be fed from the 
bottle or given in a spoon with milk. Oat jelly for infants and 
oatmeal during later childhood are especially good because 
they contain a considerable percentage of fat and a larger per- 
centage of starch than does barley. Barley jelly and wheat 
jelly are prepared in the same way. Robinson's barley, 
Granum, and Ridge's food may be used at this time. They 
are, however, comparatively expensive. 

Food for Premature Infants 

When infants are born prematurely, their power to digest food 
is much weaker than when they are born at full term. All 
the ingredients of their food should be lessened. Rotch advises 
the following formulas: 

Age Fat Sugar Protein Number op Amount at 

Meals a Meal 

28 weeks (when born) . . 1.0 3.0 0.50 24 1 dram 

29 to 32 weeks 1.5 4.0 0.50 24 2 drams 

32 to 36 weeks 1.5 5.0 0.75 24 3 drams 

36 weeks and over 2.0 5.5 1 .00 24 4 drams 

It is always well to begin with the administration of one 
dram of the milk mixture. The amount may gradually be 
increased, during the first two or three days, to the averages 
given in the foregoing table. 

Mixed Feeding 

Mixed feeding is often necessary. By it is meant the partial 
substitution of cow's milk or modified milk for the mother's 
milk. This is necessary when the mother's milk, though well 
digested, is deficient in quantity or in certain nutritive ingredi- 
ents. If deficient in quantity but well digested by the infant, 
the mother's milk should be analyzed and a substitute made as 
nearly like it as possible. If the mother's milk is deficient in cer- 
tain nutritive ingredients and the child is imperfectly nourished 
in consequence, the artificial food should so be prepared as to cor- 
rect these deficiencies, at least in part. Two, three, or four 



WEANING. 195 

feedings may be given daily. When a mother's milk is de- 
ficient in amount, it is best to lengthen the intervals between 
breast feedings by introducing a bottle of prepared milk be- 
tween them. The best indication that the mother's milk is 
deficient in quantity or quality is the failure of the infant to 
gain steadily in weight. 

Weaning 

The time of weaning children from the mother's breast varies 
greatly. Many mothers find that their milk lessens in amount 
after the first few months, and that mixed feeding must be 
resorted to. In such cases usually the diminution is slowly 
progressive and the child is weaned of necessity onto a bottle. 
The average mother who has an abundance of milk for her child 
should wean it in the tenth or eleventh month. It may be 
done one or two months earlier or later, according to the 
strength of the child and the season of the year. If possible, 
it is best not to wean babies during hot weather. It is also 
best to wean between the times of cutting teeth rather than 
while dentition is progressing. It is much better to accustom 
infants gradually to substitute foods instead of taking a mother's 
milk away suddenly. The latter must sometimes be done 
either because the mother is ill or because her milk disagrees 
with the child. In the later months of infancy most babies 
can be given full cow's milk, but it is safer to modify it in 
imitation of the mother's. To do this, an analysis of the latter 
must be made and copied in percentage milk. The modified 
milk should be changed and made to approximate full cow's 
milk as rapidly as the child's power of digestion will permit. 

The baby should be taught to drink from a glass or to eat 
from a spoon. At first such feedings should be substituted for 
one or two at the breast of the mother, after a few days for 
more, and gradually for all. 

When the child is well established upon cow's milk, it may, 
if old enough, be given oatmeal jelly with its milk once or 
twice daily. 

At all times the greatest pains must be taken to have all 
utensils, bottles, nipples, glasses, spoons, and dishes made and 
kept perfectly clean. Bottles, glasses, spoons, and dishes 



196 INFANT FEEDING. 

should be washed and scalded before they are used. Feeding- 
bottles should be rinsed immediately after use and sterilized in 
boiling water before they are again employed. Nipples should 
be boiled after use, turned inside out, and kept in cold water 
with a little sodium bicarbonate. New ones should be pro- 
cured every three or four days. 

The best feeding-bottles are those that are almost cylindric 
in shape, for they can be cleansed most easily and thoroughly. 
No rubber tubing or complicated nipples should be used, as they 
cannot be made clean or sterile with the same certainty. 

Although the food of infants is liquid, they need at times a 
drink of water also. This must not be forgotten. They should 
not be given ice-cold water, nor water with sugar in it, as is 
often done. Especially during teething is it necessary to give 
babies rather frequent sips of cold water; and with greater 
regularity in hot weather. 

Attention has already been called to the need of watching 
the weight of infants. They should be weighed regularly on a 
certain day each week, and a record should be kept of the re- 
sults. During the first five months an average gain of from 
one-half to one ounce should be made daily, or from one- 
quarter to half a pound weekly. From the fifth to the twelfth 
month the gain will be from one-third to one-quarter less than 
this. 

DIET FOR CHILDREN 

After the twelfth month of life a child's diet should gradu- 
ally be made more varied. It is still necessary, however, to 
give relatively large amounts of fat and proteins. At water 
estimates that: 

A child under 2 years requires 3/10 the food of a man doing moderate work. 

A child of from 3 to 5 years requires 4/10 the food of a man doing moderate work. 

A child of from 6 to 9 years requires 5/10 the food of a man doing moderate work. 

A child of from 10 to 13 years requires.. . .6/10 the food of a man doing moderate work. 

A girl of from 14 to 16 years requires 7/10 the food of a man doing moderate work. 

A boy of from 14 to 16 years requires 8/10 the food of a man doing moderate work. 

Considerable variation in children is noticeable during their 
second year as regards the amount of carbohydrate and protein 
that they can digest. Each one must be watched and the food 



DIET FOR CHILDREN. 1 97 

adapted to its capacity. Between the twelfth and thirteenth 
months the average child eats five meals daily. The menu 
may have upon it cow's milk, bread, oat jelly, and broth of 
chicken or mutton. Sometimes children will not swallow bread 
as early as this. Between the fourteenth and fifteenth months 
well-boiled rice may be added to the broth, and the juice of an 
orange may be eaten. After the sixteenth month a little butter 
may be spread upon the bread, or meat-juice may be poured 
over it. Prune-juice as well as orange-juice may be eaten. 
After the eighteenth month the child may have eggs. A peach 
in season, or part of a raw apple carefully scraped, may be 
eaten, especially if the baby is inclined to be constipated. 

From this time on a variety of cereals may be used. It is 
my own experience, however, that children in their second and 
third years do best upon a simple and not too varied diet. Of 
the cereals, oatmeal is best adapted to the needs of the majority. 
Only dry stale bread should be given to children. Educator 
crackers are wholesome and enjoyed by many. In the latter 
part of the second year, especially if the child is constipated, 
Graham bread or rye bread may also be eaten. A child under 
three years of age should not be given candy or sugar except 
as it is a part of other foods. A little may be put upon cereal 
foods, or later cooked in foods. If given in concentrated form, 
it is especially likely to derange digestion. 

During the last part of the second year most children may 
begin to eat meat. The breast of chicken or squab, a little 
scraped beef or lamb chop, is the best. They do not need meat 
as a daily article of diet until they are three years or more old. 
At this time a child may also begin to use some of the simplest 
vegetables, such as peas, young beans, or squash. A greater 
variety of fruits may be permitted. But for the most part 
they should be cooked. The berry fruits are especially likely 
to derange digestion. Strawberries, blackberries, currants, and 
gooseberries should not be eaten raw, and only in small quan- 
tities when they are cooked. 

The only beverages permissible for the youngest children are 
water and milk. After the fourth year a little weak cocoa may 
be given occasionally. Tea, coffee, and alcoholics should not 
be used even by older children, as these beverages affect the 



198 INFANT FEEDING. 

nervous system too strongly and lessen appetite. The deplor- 
able results of their administration to children of one, two, or 
three years of age are frequently seen by medical men who are 
practising among the poor and the ignorant. 

Game, salt food, pork (except bacon), pickles, salads, rich 
sauces, tomatoes, beets, turnips, cabbage, fancy bread, pastry, 
cake, pancakes, sweet preserves and other very sweet things, 
cheese, nuts, and fruits containing many seeds should not be 
given to children. Bacon fried hard is relished and easily 
digested, and with milk, cream, butter, and eggs, it is for them 
an important source of fat. All foods should be cooked simply. 

Children should eat only at regular times. This should be 
an invariable rule. Until they are three or four years old it is 
best that they eat alone and that they be not tempted by the 
many foods that adults eat. Even after this they should eat 
only the least hearty and the simplest meals with their parents. 
The hearty meal of the day ought not to be immediately before 
the time of sleeping. 

Between the ages of four and eighteen or twenty it is still 
necessary that relatively larger quantities of food be eaten 
than is needed in adult life, in order to provide for greater 
tissue building, greater loss of heat by radiation from the 
relatively larger body surface of youths, and generally their 
comparatively greater activity. 

Standards have not been established by the methods adopted 
in the study of adult diets, although some attempts to do so 
have been made. But enough individuals of the same age 
have not been studied to make it possible to draw satisfactory 
conclusions. Most studies have been made upon groups of 
children between the ages of nine or ten and eighteen. Aver- 
ages deduced from these studies are not applicable to all the 
intermediate ages, and much leso to the extremes. 

Average Average Average ?^?n rtinpTRs 
age Protein fat HY dra?es 

Philadelphia, 80 children 

6 to 18 years old 10 67.6 57-9 270.1 1867 

Baltimore, 115 children 4 

to 17 years old 12 65 1798 

Baltimore, 25 colored 

boys 3 to 13 yrs. old. . 9 50 1677 



DIET FOR CHILDREN. 1 99 

These figures 1 afford some idea of the habits of the children 
studied, but are too few to justify the deduction of standards. 

The United States Department of Agriculture 2 has suggested 
a standard for a child from six to nine years of 50 per cent, of 
what an adult needs and for a boy of twelve, 70 per cent. 
The United States Bureau of Labor advises 75 and 90 per cent, 
for approximately the same ages; Rowntree 50 and 60 per 
cent, and Engel 57 and 70 per cent. However, this is not a 
satisfactory basis, for the adult standard varies from Chitten- 
den's to that of Atwater's or from 2000 to 3500 calories. 

The habits of generous eating necessary in childhood are 
deleterious in more advanced life, and children as they ap- 
proach maturity and young adults especially, should be taught 
to be more abstemious. 

1 Bulletin 223, Office Experiment Station, United States Department of Agriculture. 

2 Year Book, 1911, page 365, United States Department of Agriculture. 



CHAPTER XIII 

FOOD AS A CAUSE OF DISEASE 

/// Effects of Food. Parasites and Micro-organisms. Poisoning 
by Food. Idiosyncrasies. 

For many reasons food is not always wholesome and may be a 
cause of disease. Its ill effects have been so frequently referred 
to in the preceding pages that here it is necessary only to recapit- 
ulate briefly what has been said. The ill effects of insufficient 
nourishment have already been described. 

Ill Effects of Food 

Food of itself may do harm, or it may be a carrier of patho- 
genic matter. Eating too much may be a temporary occurrence 
or may be habitual. Occasional great indulgence in overeating 
or overdrinking is much less harmful than habitual indiscretion 
of a less degree. Temporary excess produces acute gastric and 
intestinal disorders. Chronic excess produces ill effects locally 
in the digestive organs, and often generally by modifying metab- 
olism and by producing irritants to the organs of elimination. 
Indigestion, chronic gastritis, enteritis, gastric dilatation, and 
hepatic congestion are the commonest local effects of habitual 
overeating. Disturbed metabolism is shown by the develop- 
ment of such maladies as obesity, lithemia, gout, and oxaluria. 
The harm done to organs of elimination is demonstrated by 
the frequent occurrence of chronic nephritis. Not only an 
excess of food, but also food that supplies the body with its 
proximate principles out of balance, causes these maladies. 
For instance, eating too much meat, with rich gravies and 
sauces, drinking too little water, and taking too little exercise, 
will produce dyspepsia and ultimately will fill the blood with 
proteins that require a proportionately large quantity of oxy- 
gen for their complete assimilation. This is not furnished 
because insufficient exercise is taken. The products of imper- 

200 



PARASITES CONVEYED BY FOOD. 201 

feet digestion and metabolism produce various nervous and 
nutritive changes. Moreover, they especially tax the organs of 
elimination, often to the point of injury, as they are in a sense 
foreign to the human system, and the organs are not perfectly 
adapted for their excretion. 

Too little meat may be a cause of anemia. Too much salt 
meat and not enough fresh vegetables and fruits may cause 
scurvy. Improper feeding of infants leads to rachitis. Eating 
too much, especially too much of fats and sweets, may cause 
acne. Constipation is often caused by the habitual use of 
foods that are too concentrated, and do not contain sufficient 
of nature's laxative, found in water, fruit, and vegetables. 

It is true that by far the largest number of cases of illness and 
of fatal disease is due to infections, but, as Sir Henry Thompson 
writes :-" More than one-half of the disease which embitters the i 
middle and latter part of life among the middle and upper 
classes of the population is due to avoidable errors in diet."* 
Important among these is indiscretion in drinking. The ill 
effects of too little water have been described on page n, and 
of too much tea, coffee, and alcohol on pages 131, 133 and 142. 
It is not necessary to repeat what has been said. 

Parasites and Micro-organisms 

Food is commonly a carrier of pathogenic matter. Parasites, 
such as intestinal worms and trichinae, are introduced into the 
human system by infected meat. Such parasitism is entirely 
preventable, first, by proper civic or state inspection of meat 
that is used as food, and, secondly, by thoroughly cooking all 
meat before it is eaten, for these parasites are destroyed by 
cooking. Trichiniasis is caused by eating raw pork, usually 
by eating raw ham, or sausages. Intestinal worms are trans- 
mitted to man in a larval state in beef and pork that is eaten 
raw or imperfectly cooked. 

Micro-organisms are also not infrequently introduced into the 
human system by food. The danger of transmitting tuberculo- 
sis, typhoid fever, cholera, scarlet fever, and diphtheria by milk 
has been dwelt upon (p. 71). Tuberculosis may also be con- 
veyed by raw meat that has been infected. Disease caused in 
these ways can be prevented by vigilant inspection by trained 



202 FOOD AS A CAUSE OF DISEASE. 

experts of the raw foods sold in markets. The flesh of animals 
that have been slaughtered and examined according to the laws 
of the Jewish rabbis ('Kosher' meat) is free from infection. 
Cooking will destroy most parasites. Cleanliness in the prepara- 
tion and serving of foods is also necessary to prevent its becom- 
ing a carrier of disease. It has been demonstrated in recent 
cholera epidemics in Europe and in typhoid epidemics among 
the soldiers of the United States in the Spanish-American War, 
that flies, because of their filthy habits, carry disease germs 
from the excrements of the sick to the food of the healthy. 
Infection has also been caused by eating raw vegetables, im- 
properly washed, that, while growing, had been sprayed with 
liquid and contaminated manure. The utmost pains must be 
taken to have all food perfectly clean and in a wholesome 
state of preservation. 

Certain individuals who have had typhoid fever harbor the 
living virulent germs of the disease and when employed as 
cooks or in dairies as milkers or handlers of milk not infre- 
quently unwittingly contaminate food and cause typhoid fever 
wherever they live. 

Not only living parasites, but also deleterious chemical com- 
pounds, are transmitted to man by food. These may be pto- 
mains, the result of the growth of certain microbes in the foods, 
such as tyrotoxicon in milk and milk products, and similar 
poisons in shell-fish, crab meat, fish, meat, and game that is 
too 'high/ or too long preserved. Oysters and clams are 
sometimes the conveyors of living typhoid and cholera germs 
because they are grown near sewers, or at the mouth of rivers 
made foul by the sewage of cities. The meat of animals and 
birds has been known to be unwholesome because they had 
eaten poisonous plants — as, for instance, stramonium seeds. 
Cereals may carry poisons and produce such diseases as ergot- 
ism, lathyrism, and possibly pellagra. 

Poisoning by Food 

Preservation and adulteration of food are rarely causes of 
poisoning. Formaldehyd so alters flesh as to deprive it of 
flavor and renders it impervious to the gastric juice. It like- 
wise retards peptolysis. Canned meats preserved with this 



POISONING BY FOOD. 203 

agent, while of good appearance and odor, will provoke indiges- 
tion and fail to nourish. Benzoic acid, salicylic acid, boric 
acid, their derivatives and similar preservatives probably do 
little direct harm as they are usually employed. They may be 
hurtful, however, if the kidneys are not healthy and do not 
eliminate them rapidly. They likewise hinder digestion, 
although most adulterants are harmless. Their employment is 
generally and rightly condemned: first, because benzoic acid 
or its salts such as sodium benzoate may prove harmful if it is 
in many kinds of food commonly eaten because enough may be 
eaten then to do harm, although only a trifle is obtained from 
each kind. Especially are children, aged and feeble persons 
apt to be thus affected. Second, because it is not necessary 
for the preservation of foodstuffs. The best grades of pre- 
served foods do not contain it or any substitute for it. Third, 
because when preservatives are used scrupulous cleanliness 
and extreme care in handling and in selecting foods are not 
necessary. 

These have been deemed sufficient reasons for forbidding the 
sale of foods preserved with chemical preservatives by almost 
every government in Europe, as well as by experts and scientific 
societies in this country. 

Once in a while poisonous pigments are mixed with confec- 
tions and foods, but this is unusual, and in most instances 
only an accident caused by ignorance. Yet, as was traced by 
D. D. Stewart, 1 an epidemic apparently of some obscure 
infectious disease, causing fatal convulsions among children 
in one of the suburbs of Philadelphia, was due to chrome 
yellow used as 'egg coloring' for cakes and sold to hundreds 
of bakers by one of the most reputable drug houses in the 
city. Tin- and lead-poisoning have occurred from eating vege- 
tables that were preserved for many months in tin cans with 
soldered joints. It is, however, rare that poisoning is produced 
in this way unless the canned goods have been kept unusually 
long. It has been shown, however, that sometimes enough tin 
will be dissolved in three or four months from the inside of a can 
of asparagus to produce an appreciable effect, provided such food 

1 " Medical News," June 18, 1887; Third Annual Report of the State Board of Health 
of Penna., 1888. 



204 FOOD AS A CAUSE OF DISEASE. 

is eaten often and abundantly. Such forms of poisoning have 
usually been observed in isolated communities where food is 
kept for very long periods of time — as, for instance, among 
arctic explorers, among miners in distant and inaccessible places, 
among sailors on long voyages, and among soldiers who are 
suddenly assembled in large numbers and cannot at once be 
supplied with fresh food and meat, and must use whatever can 
be purchased, no matter how old it may be. 

All these facts make it evident that intelligent care should be 
taken in cultivating and feeding plants and animals which are 
to be used for food, in preparing them for the market, and 
afterward for the table. Cleanliness is essential at all times. 

Idiosyncrasies 

Idiosyncrasies lead to the production of discomfort and even 
to structural changes in some persons when certain foods are 
eaten that are wholesome for most others. Milk does not agree 
with every one. Eggs cause acute indigestion in some, and 
there are many foods that may cause urticaria in certain indi- 
viduals. Many fruits are obnoxious in one or another way to 
susceptible persons. 



PART II 
DIET IN DISEASE 



PART II 
DIET IN DISEASE 



CHAPTER I 
FEEDING THE SICK 

General Considerations of Diet of the Sick. Concentrated Foods. 
Fats and Oils. Rectal Feeding. 

General Considerations of Diet of the Sick 

In health, appetite is usually a guide as to the time when food 
is needed, but it often deceives those who enjoy food into eating 
too frequently, and those who think it necessary to satisfy it 
fully, into eating too much. Nor can appetite always be re- 
garded as an indication of the character of food to be eaten. 
Appetite contributes to our enjoyment, but it is as unsafe and 
uncertain as a guide to conduct as imagination would be. 
Many persons, however, make it their guide. This error should 
especially be avoided by the sick. They often require food 
when they do not desire it, need kinds that they relish little, and 
are satisfied before they have taken enough. However, it is 
best to gratify the taste of the sick so far as it is wise and prac- 
ticable. If they are quickly satiated, food may have to be 
given with frequency, not because they crave it, but because it 
is needed. 

To maintain health, it has been found best to eat at regular 
times. Although those who are sick may have to eat more fre- 
quently than those who are well, they also should be fed at 
regular times. Appetite — that is, the appreciation of food — 
is preserved and whetted by daintiness in serving. Only about 
so much food as the sick person ought to eat should be brought 
to him, for if a large quantity is placed before him, the sight of it 

207 



208 FEEDING THE SICK. 

is often distasteful. Therefore, it is frequently best to serve a 
meal in courses, bringing to the patient one article of food at a 
time. It should be served on dishes as pretty and attractive 
as possible, and with extreme neatness. So soon as a dish is 
emptied it should be taken away. These matters of detail, 
which pertain to the training of nurses, are of the utmost im- 
portance when there is little or no desire for food, when appe- 
tite is capricious, or when it is desirable to force more food 
upon the sick than is craved. 

Only food that is fresh and in perfect condition should be 
given to those who are ill. As a rule, it should not be twice 
cooked. Unpleasant odors, repulsive sights, disagreeable 
tastes, often disgust those who are not well and create a repug- 
nance to all food. 

Eating should be made as easy as possible for those who are 
weak. They should not be allowed to grow weary by sitting 
in an uncomfortable position or by sitting too long. 

Patients, when they are feeble, should not be awakened for 
food except under conditions of special urgency. Food, pre- 
ferably in liquid form, should always be readily accessible at 
night, so that the nurse may give it in case a patient wakens. 

Those who are too weak to help themselves must be fed. 
While they are upon a liquid diet their food may be given 
to them most comfortably through a glass tube, by means of 
which it can be sucked from a cup or bowl. A short drink of 
water can often be better given by raising the patient's head 
gently upon his pillow and placing a small cup to his lips. 

Those who are unconscious, but able to swallow, may be fed 
from a spoon or by a medicine dropper. If a patient cannot 
swallow, rectal feeding or the stomach-tube must be resorted to. 

Concentrated Foods 

A number of concentrated invalids' foods are upon the mar- 
ket. Some of them are extremely useful in increasing the 
amount of certain nutritive ingredients that are needed, and in 
helping to force alimentation when there is a disinclination to 
eat. They are important aids in the maintenance of strength — 
(i) When little food can be taken at a time; (2) when swallow- 
ing is painful or difficult; (3) when there is a disgust for food 



CONCENTRATED FOODS. 209 

and only a small quantity will be taken; (4) when it is desirable 
to force upon patients a large amount of nourishment. 

Food can be concentrated only to a moderate extent. Meat 
when desiccated affords a weight of protein equal to one-fifth 
its original weight. Sugar is the most concentrated form of 
carbohydrate. Olive oil is a type of the most concentrated oil 
or fat. 

When food is taken in concentrated form, it taxes the 
digestive organs to secrete juices to digest it, and its bulk is 
often insufficient to stimulate the stomach to muscular efforts 
adequate to expelling it promptly. So, even when food has to 
be administered in its most concentrated form, sufficient water 
should always be given to dilute it in the stomach, and to give 
a certain bulk or volume to the contents of the viscus. 

Concentrated foods are not well adapted for exclusive use, 
but they are most useful when employed to increase the per- 
centage of certain of the proximate principles of food. 

Concentrated proteins are made from milk, eggs, meat, and 
vegetables. They are sometimes partly predigested. Meat 
powder is desiccated lean meat finely ground. This can be 
made at home, or such a preparation as Mosquera's may be 
used. There are many varieties of predigested meat powder. 
They contain albumoses, or mixtures of albumoses and peptone. 
Meat powder and peptones are not agreeable to the taste of all 
patients. To disguise this taste, however, they may be given 
with other foods or beverages — as, for instance, in gruels or 
broths, or in coffee or coacoa. Somatose, which is a mixture of 
albumoses, has little or no taste and is therefore easy to admin- 
ister. A teaspoontul is equal to a half ounce of meat in nutri- 
tive value. Neutrose, eucasein, and plasmon are made from 
casein. They also are tasteless, colorless, and readily soluble. 
Aleuronat and legumin are foods composed chiefly of vegetable 
proteins. Tropon is composed of egg-albumen and protein of 
vegetable origin. 

Many of the peptone preparations upon the market do not 
contain a protein in highly concentrated form; for instance, 
Armour's wine of peptone and Fairchild's panopepton contain 
only 3 per cent. But they both contain considerable nonpro- 
tein material of food value, sugar, for instance, being an import - 
14 



2IO FEEDING THE SICK. 

ant ingredient of panopepton. The composition of several 
of these meat preparations and meat-juices has already been 
given on page 95. 

Of carbohydrates, sugar is the most concentrated, but, as is 
well known, it is not easy to digest unless diluted or mixed with 
other foods. When taken in concentrated form, it is likely to 
ferment in the stomach and to produce acids that are irritating 
to that organ. 

Malt extracts are given as foods, and some of them also because 
they contain an amylolytic ferment. As food, they contain 
carbohydrate not in its most concentrated state, and yet so 
concentrated as to be somewhat indigestible. As the sugar 
in malt extract is glucose, it is less indigestible than ordinary 
syrup, but not more nutritious. It is not so easy of digestion 
as honey, and is more liable to ferment and is more inclined to 
satiate or destroy the appetite than a quantity of milk-sugar 
that is its nutritive equivalent. The amylolytic ferment that 
some of the malt extracts contain does not make them so useful 
as digesters as Taka-diastase and some other preparations of 
diastase are. 

Fats and Oils 

Fats are often emulsified for administration to invalids. This 
is done partly to disguise their taste nd partly with the hope of 
making them more digestible. The taste is undoubtedly im- 
proved. It is doubtful if the digestibility is much increased. 
When oils or fats are needed, it is usually best to give them as 
cream, butter and bacon, for they are best relished in these 
forms. The emulsions are sometimes useful additions when 
they will be taken by patients as medicines and their equivalent 
rejected as foods. 

Oils are often rubbed upon the skin and absorbed from it. 
They may help to nourish a very weak patient when adminis- 
tered in this way. Olive oil, cacao-butter, and cod-liver oil 
are the kinds usually employed for endermic administration. 
Sterilized olive oil may be injected hypodermically. An ounce 
a day given in this way has been found to lessen nitrogenous 
waste materially. Its injection does not cause pain. Sterilized 
grape-sugar will cause intense pain when injected hypodermic- 



RECTAL FEEDING. 211 

ally. Proteins cannot be sterilized without precipitating them, 
and, therefore, cannot be injected beneath the skin. There is 
one exception to this general rule: Serum can be sterilized at 
55 C. without precipitating its albumin. It has been given 
through the hypodermic needle, but the amount of nutriment 
thus administered is insignificant. 

Rectal Feeding 

Rectal alimentation must be resorted to whenever food can- 
not or will not be swallowed, cannot be retained in the stomach, 
causes intense pain in throat or stomach, when too little can be 
taken by the mouth to maintain strength, or when food is not 
absorbed from the stomach or passed on into the intestines, 
as when there is cancer of the pylorus, or when it is desirable to 
rest the stomach, as in cases of gastric ulcer and severe gastritis. 

The power of the rectum to absorb foods has been studied 
carefully. Peptone is well absorbed from it. So is white of 
egg, provided a little salt is mixed therewith. Raw beef-juice 
is also completely absorbed. Milk proteins and gelatin are not 
well absorbed. Sugar is easily absorbed, but is especially 
likely to provoke diarrhea, or at least its quick expulsion; for 
in concentrated solution it irritates the mucous membrane of 
the bowel. It should not be introduced into the rectum in 
more than from 10 to 20 per cent, solutions. Starch is quite 
as perfectly absorbed as sugar and is not irritating. Fats are 
poorly absorbed. It is evident, therefore, that the best ingred- 
ients of which to make nutritive enemata are peptones, albu- 
moses, eggs with salt, raw beef-juice, and starch. How it 
happens that undigested egg-albumen, meat -juices, and starch 
are perfectly absorbed from the rectum has not yet been 
explained. Probably the epithelial cells of the mucous mem- 
brane are capable of modifying them chemically. It has also 
been shown that a reversed peristalsis takes place, and that 
food introduced into the rectum reaches the small intestine if 
there is no obstruction in the intestinal tract. 

Not more than a large cupful (250 c.c, or eight ounces) of 
liquid food should be put in the rectum at one time, and the 
nutritive enema should not be repeated oftener than every six 
hours. The food should be warmed to the temperature of the 



212 FEEDING THE SICK. 

body before it is administered, and should be introduced slowly. 
The best way is to pass into the rectum ten or twelve inches of 
soft-rubber catheter, to which is attached a rubber tube and a 
funnel or bag that will hold eight or ten ounces of fluid. It is 
best to use a large catheter, or preferably a colon tube of about 
3/8 inch in diameter, and sufficiently thick to prevent recurva- 
tion. This can be attached directly to the funnel or reservoir. 
Before the catheter is inserted into the rectum the whole tube 
must be filled with the fluid to be used, so that no air will be 
forced into the bowel. By raising the funnel two or three feet 
above the level of the patient the enema will slowly enter the 
bowel. The fluid can be made most readily to flow high up 
into the colon, and can be retained best if the patient lies upon 
his left side, with his hips slightly elevated upon a pillow, and 
with his knees drawn up. After the fluid has been placed in the 
bowel, the catheter should be slowly and gently removed and 
pressure with a clean towel made against the anus to help the 
patient to hold the enema. The patient should lie still for an 
hour. If these nutritive injections are not well retained, a little 
opium may be added to the mixture. 

Nutritive enemata can be given as water and saline enemata 
are frequently, continuously by the drop method described on 
page 11. From a vessel one and one-half or two feet above 
the patient the enema is conducted into his rectum by a rectal 
tube in which there is a stopcock which can be so set that the 
fluid will flow into the rectum drop by drop. The enema must 
be kept at body temperature. It is usually well absorbed when 
given in this way. 

Although food can successfully be given by the rectum, 
enough cannot be given to maintain strength fully. Food 
that will generate more than 500 calories daily cannot be 
administered by enemata. This is from one-fourth to one- 
fifth of what an adult needs. 

Enemata are best absorbed if the bowel is kept clean; there- 
fore, at least once daily the colon should be flushed. The 
addition of common salt also contributes greatly to the readi- 
ness with which nutritive injections are absorbed. 

The articles of food most frequently used for rectal alimen- 
tation are peptonized milk (see p. 79) or peptonized milk to 



RECTAL FEEDING. 213 

which white of egg or starch and salt are added. Leube recom- 
mends formulas like the following: 

Peptone 60 grams (2 ounces) 

Milk 250 c.c. (8 ounces). 

3 eggs 

Salt 3 grams (3 1\ dram) 

Milk 250 c.c. (8 ounces). 

Grape-sugar 60 grams (2 ounces) 

Milk 250 c.c. (8 ounces) . 

Starch 60 grams (2 ounces) 

Milk 280 c.c. (9 ounces). 



Leube has also advised a pancreas enema made by mixing 60 
grams (2 ounces) of minced pancreas, 200 grams (7 ounces) of 
minced meat, and 30 grams (1 ounce) of fat. It is supposed 
that the pancreas and its juices will aid digestion in the colon. 

A good nutritive enema can be made of the whites of three 
or four eggs, two ounces of starch, a teaspoonful of salt, and 
eight ounces of water. To this may be added, if desired, pan- 
creatic extract and sodium bicarbonate. Nutritive supposit- 
ories have also been made, but, although easily administered, 
they do not furnish so much nourishment nor are they so per- 
fectly absorbed as are enemata. 



CHAPTER II 

DIET IN INFECTIOUS DISEASES 

Typhoid Fever. Typhus. Dysentery. Yellow Fever. Cho- 
lera. Dengue. Relapsing Fever. 

TYPHOID FEVER 

Indications for the diet to be prescribed for those suffering 
from typhoid fever are afforded, first, by the existence of acute 
inflammation in the intestines. Such a lesion anywhere in the 
gastro-intestinal tract indicates a liquid diet. Second, by the 
enfeebled digestion, which makes it necessary to use only food 
that can be directly absorbed or easily digested. Third, by 
malassimilation, which is so considerable in all severe cases as 
to make it impossible during the period of pyrexia to restore 
strength and flesh. Food must be given, however, to lessen or 
retard this loss of strength and flesh. 

In mild cases, during the first days of illness, appetite is 
diminished and capricious. At this time it is necessary often 
to vary foods so as to tempt the patient to eat. The variety 
must be chosen from liquids. Milk should form the main 
staple, but beef-juice, chicken broth, clam broth, oyster broth, 
custard, weak tea or coffee, and gruels may also be given. In 
severe cases, after the first few days, the mental sluggishness 
or indifference that the disease produces makes it possible to 
adopt a monotonous but nutritious regimen. Patients are 
more inclined to complain because they are disturbed too 
frequently by the offer of nourishment than because of the kind 
of nourishment they are given. As convalescence approaches 
and is finally established, hunger demands quantity of food, and 
solid food, more than variety, although a varied diet is fully 
appreciated. During the febrile stage patients must be fed 
and given drink at specified times and in prescribed amounts, 
because they are mentally so indifferent or somnolent that they 

214 



TYPHOID FEVER. 215 

rarely ask for either food or drink. While not to be over- 
crowded with food, and, as a rule, not to be disturbed during 
sleep, their appetite must not be considered by nurses a guide as 
to the frequency with which food is to be given to them. On 
the other hand, when convalescence is first established, the 
extreme hunger of typhoid patients must not tempt physicians 
or nurses to give solid food too quickly or too plentifully. 
In uncomplicated cases a milk diet should be adhered to until 
a normal temperature has been maintained four or five days. 
During the next four or five days food should be liquid, but 
can be varied. When the temperature has been normal in the 
evening for a week, soft or semisolid food may be given. A 
few days later finely divided meats may be tried, and slowly 
the patient may be allowed to return to a mixed diet such as 
is usual in health. 

Milk is the best food for those having typhoid fever, as it con- 
tains in liquid form the ingredients essential for the main- 
tenance of bodily temperature, strength, and repair of waste. 
Milk-sugar and the fat of cream are easily prepared for absorp- 
tion, and the protein of milk is, as a rule, readily digested. 
These ingredients do not commonly undergo fermentation in the 
gastro-intestinal tract which will produce toxic bodies. The 
salts of milk are almost identical with those of blood. Milk 
is an efficient diuretic and stimulates elimination by the kidneys, 
which is also important in lessening typhoid intoxication. 
All these qualities of milk make it a particularly good food for 
typhoid fever patients. From two to three pints of it should 
be given one daily. It is best to give a glass or half glass at a 
time. It is also well, when possible, to give it ten or twenty 
minutes after a Brand bath. 

Occasionally milk is found to disagree with typhoid patients. 
This is sometimes due to giving too much of it. Friends will 
now and again crowd two quarts or more a day upon the sick. 
With impaired powers of digestion, this may be more than the 
stomach can tolerate, and it may be vomited as a soured and 
curdled mass. At other times it disagrees with them because 
it clots with abnormal rapidity. Excessively rapid curdling 
and consequent vomiting can frequently be prevented by adding 
lime-water or barley-water to the milk, or by thickening it 



2l6 DIET IN INFECTIOUS DISEASES. 

with wheat flour. Better than any of these additions is a 
modification of milk, so that the proportion of protein in it will 
be 1.5 or 2 per cent, instead of 4. This can be accomplished 
by mixing one part of cream with three of boiled water, and 
three and one-half parts in 100 of milk-sugar. (See p. 186.) 
It is often helpful to 'pancreatize' the milk given to patients 
having typhoid fever. In the ordinary case, two grains of 
pancreatin and six grains of sodium bicarbonate dissolved in 
one ounce of cold water are stirred into four ounces of luke- 
warm milk, and this is at once given to the patient, who drinks 
it slowly and is usually unaware that anything has been added 
to the milk. This quantity is given every two hours. In rarer 
cases milk must be peptonized or partly digested before it is 
given. This, however, is necessary only in very exceptional 
cases. Patients who suffer from protein indigestion are often 
much helped by the administration of hydrochloric acid and 
pepsin. 

Typhoid patients who are mentally dull rarely object to any 
food that is given to them, but a few of those who are not, have 
so intense a dislike for milk that enough nourishment cannot 
be administered to them if milk alone is used. In such cases it 
is necessary to find some substitute for it. Mellin's food, 
malted milk, and similar food-products may be used, or gruels of 
wheat or barley. These last should be strained to remove solid 
particles. Patients will frequently take kumiss and buttermilk 
or whey when they refuse sweet milk. Many others will take 
custards, or milk with a raw egg beaten up in it, when they 
will take neither of the other preparations. Ice cream in 
moderation is also often unobjectionable. 

It must not be forgotten that many persons who have a 
prejudice against milk can be taught to take it if it is fed to 
them from a spoon at first, in doses of two or three teaspoonfuls 
at a time. 

Those who cannot tolerate milk in any form must depend 
upon bouillon. It is not sufficiently nutritious of itself. It can 
however, occasionally be fortified by adding an egg to it or by 
giving an egg lemonade in its stead. A little soft-boiled rice 
may sometimes be added to bouillon with benefit. The bouil- 
lon is absorbed directly, almost without digestion. The egg 



TYPHOID FEVER. 217 

and rice require digestion. Bouillon, however, stimulates 
strongly the peptic glands and excites an increased flow of 
gastric juice. It restores the mineral salts of the blood, which 
are rapidly eliminated during the period of fever. So consid- 
erable is this elimination that a mineral inanition is sometimes 
threatened. In such cases bouillon must be given in quantities 
of from one to one and one-half pints daily. It is so useful as 
a stomachic and a restorer of mineral matter that it is well to 
give it in small amounts to all typhoid patients. From time to 
time gruels can be given instead of milk to increase the total 
calories which the patient receives, or, better, farinaceous foods 
can be added to the milk to slightly thicken it. Egg and milk 
mixtures can also be given for the same purpose. The fat of the 
egg and the sugar which goes into the mixture increases the 
caloric value of the food. Such substitutes can be made two 
or three times daily in many cases with advantage. 

Patients also need to be given an occasional drink of water. 
Unless specially instructed, nurses frequently neglect this. 
They wait for the patient to ask for a drink, and he is often too 
dull to do so. Lemonade is craved by many and is harmless. 
Tea and coffee may be permitted in small amounts when they 
are desired. Coffee is decidedly useful in extreme cases when 
the heart is weak or failing. It should be given then as a strong 
decoction. A half-pint may be allowed daily. The simpler 
diet of milk, or milk and bouillon, is to be preferred, however, 
except in those rare cases when a variety seems necessary to 
satisfy a patient's cravings or caprice. 

Fruit-juices, such as orange-juice and grape-juice, and jellies 
are relishes that are not only harmless, but mildly nutritious, 
and are much enjoyed by fever patients. 

Drinking copiously of liquid foods and water increases tissue 
oxidation, but does not increase disintegration; therefore elim- 
ination of waste-products becomes more perfect. By intro- 
ducing much fluid into the circulation, waste-matters are 
washed from the tissues and rapidly carried to the organs of 
excretion. It also lessens the concentration of the blood, which 
is considerable during the first half of the course of typhoid 
fever, and therefore prevents exosmosis from the tissues. Elim- 
ination by the kidneys is increased because blood tension is 



2l8 DIET IN INFECTIOUS DISEASES. 

greater. The noxious matters in the blood and lymph are 
diluted and become less irritating to the nervous system and 
emunctories. The typhoid state is consequently less pro- 
nounced when fluids are drunk freely, and the kidneys, liver, 
and muscles are less likely to degenerate. 

In the worst cases it is often impossible to give enough fluid 
by the mouth to obtain these desirable results. Water and 
food must then be given by the rectum. Water can be given 
also subcutaneously with advantage. For this purpose, phys- 
iologic saline solution is to be preferred, and necessary precau- 
tions must be taken for aseptic injection. 

It is not safe to give solid food until a normal temperature 
has been maintained a week or ten days and the patient's 
stools have lost the typhoid characteristics. My own rule is to 
wait a week in cases of average severity, but to try a soft- 
cooked egg by the fourth or fifth day, and a little milk-toast 
by the sixth. After this an approach to solid food can be made 
by using custards, corn-starch, and rice pudding, finely chopped 
or scraped meat, and creamed codfish; then dry bread with 
meat -juice or fruit jelly; the breast of pigeon or chicken, a 
chop, mashed and baked potato. These changes in diet must 
be made slowly and tentatively. If, however, any rise of tem- 
perature is noticed, it is best to return to the liquid diet, or at 
least lessen the amount of food eaten. If recovery goes on 
uninterruptedly during the first week after beginning the change 
of diet, there is little danger of harm from solid food. 

The following menu illustrates the changes of diet which may 
be made when the change from liquid to solid foods is started : 

First day, soft-boiled or poached egg. 

Second day, milk toast, chicken or mutton broth. 

Third day, scraped beef, boiled rice, wine jelly. 

Fourth day, cornstarch or arrow-root, milk toast, eggs or 
scraped meat or custard and fruit jelly. 

Fifth day, chicken or squab or oysters, baked potato or rice, 
apple sauce or fruit jelly or jelly, etc. 

Sixth day, in addition to milk and other foods previously per- 
mitted a somewhat larger quantity and variety can be given. 

Although the dietetic management just described is the one 
admitted by most eminent clinicians to be the best in typhoid 



TYPHOID FEVER. 219 

fever, attention must be called to the usage of a few who feed 
their patients much more generously. They give the liquid 
foods mentioned, but also gruels, eggs, minced meat, boiled 
rice, milk toast and similar foods. They attempt to give food 
which will produce 2000 to 3000 calories. In exceptional 
cases I have used this diet but it does not seem to meet the 
indications of the disease as well as the other. 

Some relapses certainly date from the time of feeding patients 
too much food or food too difficult to digest, and they are gen- 
erally supposed to be thus caused. Improper feeding, how- 
ever, is not the chief cause of relapse; yet it may be a factor, 
and is an avoidable one. While the safest rule as to the time 
of changing from an exclusively liquid diet is that just stated, 
rare cases are met with in which a low fever persists for many 
days after the bowel movements have become normal and 
typhoid symptoms have disappeared. This is especially liable 
to occur in patients who are greatly debilitated from a prolonged 
course of fever and who have become greatly emaciated. This 
fever is frequently spoken of as a fever of inanition. To such 
patients food must be given more generously and be of a semi- 
solid character even before the fever disappears. Indeed, the 
fever will cease sooner if such food be given than if it be with- 
held. In such cases the temperature is usually normal, or 
almost so, from about midnight to midday. This is the time 
when semisolids are best given. During the hours of pyrexia 
the food should be liquid. 

Meteorism is sometimes due to milk indigestion or to carbo- 
hydrate indigestion, but often more to relaxation of the intes- 
tinal wall and consequent imperfect expulsion of gas. A tem- 
porary change from milk to broths fortified with somatose or 
egg-albumin or the omission of carbohydrates if they have 
been used, helps. Turpentine stupes, enemata and an ice-bag 
usually do more good. The administration of intestinal anti- 
septics are of little avail. 

If a hemorrhage occurs complete intestinal rest should be 
insured by stopping the administration of foods for twenty-four 
hours at least. A little water or ice can be given. A 2 per 
cent, solution of gelatin slightly acidulated with lemon and 
kept cold can also be given partly to lessen thirst and partly 
for the styptic affect of the gelatin. When the administra- 



220 DIET IN INFECTIOUS DISEASES. 

tion of milk is again begun, it should be fed in spoonfuls every 
one or two hours and very gradually increased in amount. 
Complete bodily rest should be assured. Opium is often needed 
to stop peristalsis. An ice-bag upon the abdomen is also a 
help. 

Alcoholic beverages were formerly used with great freedom 
in all fevers. During the last few years they have been employed 
less and with more discretion. I have already so fully dis- 
cussed their physiologic action and character that it is necessary 
here only to refer to the former chapter devoted to them, and 
to repeat that they should be avoided in the absence of positive 
indications for their use. 

TYPHUS FEVER 

In this disease the dietetic indications are to maintain strength, 
avoid irritation of the kidneys, and promote elimination by the 
various emunctories. Special difficulty in feeding is encoun- 
tered in many cases because of stupor or delirium. As in all 
diseases in which temperature ranges high, the ability of the 
digestive organs to do their work is lessened. Food should, 
therefore, be given in a form in which it is easily digested. 
Milk is the best food to depend upon. From one and one-half 
to two pints should be given daily. It is well to give also 
bouillon, or, better, meat-juice. These often prove more grate- 
ful when taken cold than hot. If they are slightly acidulated 
with lemon, they are better liked by the patient. An agreeable 
and nutritious drink can also be prepared by whipping up an 
egg in lemonade. This is best given in the milder cases and 
especially to those who do not have albuminuria. Gruels may 
be substituted for part of the milk, and may be given especially 
to those persons who do not tolerate milk. Milk, bouillon, 
gruels, and custards form the staples of diet. During the 
period of pyrexia all food should be given in small portions and 
often. In this way it is least likely to overtax the stomach. 

Drinks are craved and should be given freely. They may 
consist, in addition to the liquid foods just mentioned, of water 
and acidulated or carbonated waters. Copious drafts of fluid 
promote a healthier metabolism and aid in the dilution and 
elimination of toxins. Liquid foods and bland drinks will 



DYSENTERY. 221 

avert, so far as one can avert such accidents, irritation of the 
kidneys or serious permanent lesions of these organs. 

After crisis, semiliquid food may be given, and in one or two 
days, solid foods. In mild cases soft foods, meat jellies, soft- 
cooked eggs, corn-starch, and similar bland articles may be 
administered during the entire course of the disease. In some 
severe cases anorexia makes feeding extremely difficult. Stom- 
ach-feeding must sometimes be supplemented for a few days 
by rectal feeding. Great care should be taken in these cases 
that a sufficient amount of water is absorbed to keep the kid- 
neys acting, and the toxins well diluted. 

Alcohol is needed only in exceptional cases. What has al- 
ready been said of its indications and counterindications must 
be borne in mind. 

DYSENTERY 

Too much emphasis cannot be placed on diet in dysentery. 
Dietetic treatment will effect a cure in mild cases and diminish 
the gravity and duration of severe ones. Errors in feeding are 
a frequent source of relapses and exacerbations. During the 
first day or two, when the stomach is extremely irritable, it is 
often well to give little or no food. At this time it is important 
to empty and cleanse the bowel, which cannot be accomplished 
well if food is given persistently. But it soon becomes neces- 
sary to administer food both in order to maintain the patient's 
strength and to lessen his feeling of hunger. So far as possible 
food should be such as will leave little residue in the lower bowel 
to putrefy and to irritate it. An exclusive diet of milk is gen- 
erally recommended. If the stomach as well as the intestine 
is irritable, it must be given in small amounts frequently. An 
exclusive milk diet is as useful in chronic dysentery as in the 
acute form of the disease; but rarely need be enforced, how- 
ever, except during acute exacerbations. 

When a diet consisting exclusively of milk cannot be main- 
tained, it may be varied by administering bouillons, meat-juices, 
clam broth, soft-cooked or raw eggs, and fish. Beef-tea, home- 
made beef-juice, or the meat-juices of the shops, such as Val- 
entine's or Wyeths, may be given advantageously in alterna- 
tion with milk. For those who cannot tolerate milk, beef- 



222 DIET IN INFECTIOUS DISEASES. 

juice must be used as the main article of diet. About one 
quart should be given daily whenever it is possible. In severe 
cases this can best be accomplished by giving two or three 
teaspoonfuls every ten or twenty minutes. Both milk and 
beef-tea or meat-juices can be made more nutritious by some- 
times adding an egg to them. In mild cases the patient will 
tolerate and be benefited by the use of shredded fish — as, for 
instance, salt codfish — or a boiled fresh fish. A soft-boiled or 
poached egg can often be given without harm, and it will be 
relished. During beginning convalescence, and in chronic cases 
during periods of remission, oysters, or a squab, or a little of 
the breast of young chicken, may be given, and, later, when re- 
covery seems most certain, finely chopped or scraped beef 
entirely free from fat and, as far as possible, from fibrous tissue. 
When a more varied diet is craved, farinaceous foods must be 
allowed very sparingly. Gelatin jellies and custards will give 
some variety. Bread can safely be given in the mildest cases 
only; nor should it be given at first until after it has been 
thoroughly dried. Zwieback and pulled bread are the best 
kinds. , 

Demulcent drinks, such as barley-water, rice-water, weak tea, 
and albumin water, are often grateful to patients and slightly 
nutritious. In chronic cases, when emaciation is considerable, 
inunctions of olive oil and of cod-liver oil may be resorted to, 
as aids to the maintenance of strength and restoration of flesh. 

YELLOW FEVER 

In mild cases, yellow fever requires little more than careful 
nursing. In severe cases strength is lost with great rapidity; 
therefore the administration of food is imperatively demanded, 
but vomiting prevents its being taken by the mouth. If 
patients are strong when stricken by the malady, no food should 
be given during the first two or three days. This rule does not 
apply to the mildest cases, in which vomiting occurs infre- 
quently, so that a few spoonfuls of liquid nourishment may be 
given to the patient quite often. Cracked ice, effervescing 
waters, and champagne are sometimes given to check vomiting. 

Constant vomiting and abstinence from food and drink 
diminish all the secretions. The urine becomes scant or almost 



YELLOW FEVER. 223 

suppressed. To prevent this, water must be given by the 
rectum or by hypodermic injections. A decinormal (physio- 
logic) saline solution should be used for these purposes. Al- 
though a strong patient may be starved for two or three days, 
it is rarely advisable to withhold nourishment for more than 
two or three days, and in the severest cases strength is lost so 
rapidly that some nourishment muse be given from the start. 
Fortunately, in yellow fever the rectum is very tolerant, and 
alimentation may be maintained by it. Nutritive enemata 
can be given continuously by the drop method described on 
page 211 or as a single injection at regular intervals which is 
the usual method. Peptonized milk is the best form of nourish- 
ment to administer in this way. It is best to give enemata occa- 
sionally even when the stomach tolerates a little liquid nourish- 
ment, as the latter organ can never be relied upon and is so 
sensitive that it becomes rebellious if ever so little overtaxed. 
For this reason it is safest to continue to give nutritive enemata 
in the second stage or during the remission, although a few 
spoonfuls of liquid nourishment are also given every twenty or 
thirty minutes by the mouth. In those cases in which recovery 
commences at this time larger amounts may be given very 
slowly and tentatively. As, however, in many other cases a 
recurrence of severe vomiting is to be expected after an inter- 
mission of a few hours, stomach-feeding is 0/ little value and 
may be harmful if not conducted with greatest prudence. 
When vomiting begins to be less frequent and severe, one or 
two spoonfuls of milk, kumiss, or beef-tea or diluted meat- 
juice may be tried. If retained, the amount may be increased 
slowly, but rectal alimentation should be kept up and food 
should not be crowded upon the stomach. The digestive power 
of this organ is often greatly lessened for many days, and some- 
times even for months, after an attack of yellow fever. When, 
in cases of moderate severity, convalescence has been estab- 
lished for ten days or two weeks, soft foods may be eaten with 
the liquids, such as gruels, milk-toast, junket, farina, custards, 
soft-boiled or poached eggs, crackers, Mellin's food or malted 
milk, minced chicken, and scraped meat. The highly albu- 
minous articles, such as eggs, custards, chicken, and meat, 
should not be given so long as there is albuminuria. The 



224 DIET IN INFECTIOUS DISEASES. 

kidneys will be most certain to retain their functional activity 
if physiologic saline solution be given by rectum or hypoder- 
mically during the period of the greatest severity of the malady. 
When uremia develops, the blood should be diluted as rapidly 
as possible in these ways, and diaphoresis should be stimulated 
by the hot pack or bath. 

CHOLERA 

In cholera, infection takes place through the mouth. In 
almost every instance water conveys its cause. Occasionally, 
even when the greatest care has been taken to drink only pure 
water, the disease is conveyed by raw vegetables, fruits, or 
dishes and utensils that have been washed in impure or infected 
water. The infectious microbes may also be carried from 
excreta or infected water to food by flies or other insects. 

Prophylaxis 

For the prevention of cholera in times of epidemic, the follow- 
ing rules should be observed: (i) Raw food, such as vegetables 
and fruits, should not be eaten, as it may have been washed in 
water that had been contaminated. (2) All water used for 
cooking, for washing dishes, glasses, and cooking utensils, 
should be sterilized. Beer, ale, soda-water, or artifical mineral 
water made from water not sterilized should not be used. (3) 
Water used in brushing the teeth or cleansing the mouth should 
be sterilized. (4) Ice should not be put into water that is to be 
drunk, or on vegetables or fruits, as it may contaminate bever- 
ages or foods that are otherwise wholesome (5) Food of all 
kinds must be protected from contamination by flies. (6) 
Acid drinks should be taken freely, for they are inimical to 
cholera germs. It is probable that the acid state of the stomach 
in health is one cause of the immunity that many persons enjoy. 
Lemonade acidified with dilute sulphuric acid — from ten or 
fifteen drops of the latter to the glass — has been extensively 
used during epidemics of cholera. Dilute hydrochloric acid 
may be substituted for the sulphuric, or tartaric or citric acid 
may be used. A palatable acid beverage may be made by 
dissolving one-half ounce of tartaric acid in a quart of sweetened 
water. The contents of the stomach, kept hyperacid by these 



CHOLERA. 225 

drinks, will escape from time to time into the duodenum and 
make it temporarily acid. The growth of the cholera bacillus 
may thus be inhibited or prevented. 

Indigestion should be avoided by careful eating, or, if existing, 
should be corrected at once. Disturbance of the stomach, 
especially such indigestion as causes diminished acidity or alka- 
line fermentation, opens an avenue for the entrance of the 
specific infection. 

During a cholera epidemic those foods that are liable to pro- 
duce indigestion or diarrhea must be avoided. All food should 
be in a perfect state of preservation and well cooked. Care 
should also be taken not to overeat and not to overfill the 
stomach, even with pure water, for the latter will only dilute 
the contents of the stomach and make them less acid, and thus 
less capable of digesting food, or of destroying the cholera 
microbe which may chance to find its way there. Food must 
also be cooked simply. Fried dishes, those served with rich 
sauces, or made very sweet, should be avoided, as they are a 
common cause of indigestion. 

Treatment 

During an attack of cholera very little food can be given, for it 
often aggravates vomiting, and, if retained, forms a culture- 
medium for the cholera bacillus and therefore a source of more 
toxin. In the stage of premonitory diarrhea, and in the stage 
of resolution, a moderate quantity of food is permissible. In 
the first, if vomiting does not prevent, a little pancreatinized 
milk, bouillon, whey, gruel, or matzoon may be given. No 
attempt should be made to give much food, for it is very easy 
to overtax the stomach and do harm. 

Acid beverages should be given as freely as possible. Those 
recommended as prophylactic may be employed. During the 
epidemic of cholera in Paris, in 1892, the Council of Hygiene 
recommended water acidulated with lactic acid. Hayem 
first demonstrated the utility of lactic acid in the green diarrhea 
of infants. Dujardin-Beaumetz prescribed this formula: 
Lactic acid, 10 grams; simple syrup, 90 grams; essence of orange 
or lemon, 2 grams; water, sufficient to make 1000 grams. It 
was to be taken in doses of a dessertspoonful or tablespoonful 
is 



226 DIET IN INFECTIOUS DISEASES. 

every quarter of an hour. However, in this and subsequent 
epidemics the utility of lactic acid was variously estimated by 
clinicians. In France, such men as Peter, Sireday, Delpeuch, 
and Barie found it useful. Others believed it worthless. It is 
probably of some value, at least in mild cases. 

When the strong acids are given, they should be taken 
through a glass tube in order to save the teeth. Sometimes 
acid drinks seem too strong and are quickly vomited. However, 
if they are given in sips, and a bit of pure ice is taken after each 
sip, they will often be retained when they would not be under 
other circumstances. 

Acid drinks taken in sips, iced lemonade, or Seltzer often 
check vomiting. Sinapisms on the epigastrium and various 
anti-emetics may also be tried to relieve it. 

Water must be regarded in the treatment of cholera as both 
a medicine and a food. Enteroclysis has been employed in 
numerous epidemics. It was used extensively and regarded 
with favor by the physicians of Hamburg in 1892. Water 
should be introduced into the rectum as high as possible by 
inserting into it a long rectal tube. As much as two quarts of 
hot water should be injected at a time, slowly, and under 
moderate pressure. Cantani recommended the addition of 
three grams of tannic acid to the water. Others used a 4 per 
cent, solution of boric acid, and still others soap and water or 
sodium chlorid solution. The rectal tenesmus is usually 
lessened or removed by this treatment. Most of those who 
have used such treatment believe that not only is the bowel 
cleansed, but that some water is absorbed, replacing a part of 
the fluid that is constantly drained from the blood-vessels 
and removed from the body by purging and vomiting. Acid 
drinks and the acid enemata constitute the most important 
items of treatment in the first stage of the malady. 

Although the attempt has been made to destroy cholera 
microbes by acid drinks and to remove them by enemata, or 
rarely by gastric lavage, it has seldom been more than partly 
successful. It is as important to remove the toxins as to 
destroy and remove the bacillus of cholera. This can best be 
accomplished by diluting the blood and the interstitial fluids 
with water, and by promoting rapid elimination through the 



CHOLERA. 227 

kidneys ; for, on account of the rapid elimination of fluid by the 
bowels and stomach, the blood becomes concentrated and the 
interstitial tissues grow comparatively dry. This rapid drain- 
ing of the tissues is the first, though not the only, cause of the 
collapse that is so often present in this disease; collapse is 
ultimately and chiefly due to poisoning by compounds pro- 
duced by the germs of cholera, and held in solution in the blood. 
It is, therefore, necessary, not only to restore water to the 
blood-vessels and tissues, but to flood them with it in order to 
dilute the toxins and to stimulate the kidneys. Enemata help 
to accomplish these objects, but are often unavailing, partly 
because of frequent purgations, and partly because absorption 
from the intestines is very imperfectly performed. In 1830 
Joehuichen (Moscow) first used intravenous injections of water. 
He acidulated it. In 1832 Latta (Scotland) advocated a 
solution of common salt. This has been found the most useful. 
Intravenous infusion is recommended when patients are in a 
state of collapse — that is, cold and pulseless at the wrist. Some 
physicians resort to it whenever the radial pulse is too small to 
feel. However, the mortality has been reduced so slightly by 
this means that it is doubtful if the few men apparently saved 
by it would not have gotten well without it. The immediate 
effect of intravenous infusion upon patients apparently mori- 
bund is often remarkable and most satisfactory. Hayem 
says: "One seems to aid at a genuine resurrection." The 
best solution to use is that recommended by him: 

Water 1000 parts 

Pure sodium chlorid 5 parts 

Sodium sulphate 10 parts 

Of this mixture, from one and a half to two liters (quarts) 
should be used. It should have a temperature of from 3 8° to 
39 C. (ioo° to 102 F.). The intravenous injection should be 
made with the strictest aseptic precautions, and no air should 
be admitted to the vein. At least five minutes, and, better, a 
longer time, should be taken to inject the water into the vein. 
Although the happiest results often follow venous infusion, 
it is an operation not without danger. The admission of air to 
a vein, the production of pulmonary emboli, the admission of 



228 DIET IN INFECTIOUS DISEASES. 

septic germs, phlebitis, lymphangitis, and gangrene are some 
of the dangers incurred. 

In 1883 the much safer and almost, if not quite, equally 
efficacious procedure, hypodermoclysis, was devised nearly at 
the same time by Samuels (Konigsberg) and Michael (Hamburg). 
The results of hypodermoclysis are less prompt and less bril- 
liant, but often more permanent than those of intravenous 
infusion. The hypodermic injection of a salt solution is com- 
paratively free from danger. The same aseptic precautions 
must be taken as in intravenous infusion. Hayem's solution 
is one of the best to use. It should be injected into the loose 
cellular tissue of the body, in amounts varying from 150 to 
450 c.c. (5 to 15 ounces). These injections may be repeated 
several times in one day, and for several days in succession. 
The temperature of the fluid should be that of the blood. The 
injections should be given as soon as the algid state develops 
or threatens. Do not wait too long. 

B. W. Richardson advised the intraperitoneal injection of hot, 
sterile milk (about 43 C. or 109 to no° F.) for the double 
purpose of supplying fluid and heat. He selected milk as an 
animal fluid less likely to be irritating than an artificial blood 
serum, and with the hope that it might likewise be an aid 
to nutrition. The procedure has not been sufficiently practised 
to permit an estimate of its value. 

Although water administered in various ways is so essential, 
food, because it is rarely retained or assimilated, is not of much 
utility during the height of the disease. When recovery begins, 
peptonized milk and broth may again be tried, at first in doses 
of a teaspoonful. If the food is retained, it may be given in 
the same way every fifteen minutes. After a few hours the 
quantity may be very slowly increased. There is great danger 
of overtaxing a stomach already extremely irritable, and from 
which absorption is imperfect, even with a very small quantity 
of nourishment. When food is tolerated, milk not predigested 
may be tried. From this time on, the same gradual change in 
the amount and character of food must be made as during 
convalescence from typhoid fever. 

Body temperature should be maintained so soon as it falls 
below normal, by heat applied to the outside, by hot water bot- 



DENGUE. 229 

ties, or sometimes by immersing a patient for hours in a bath 
of hot water. This last procedure also makes possible the 
absorption of some water by the skin. 

DENGUE 

The diet should be the same as for other mild febrile maladies. 
Liquid foods and cold acid drinks, like lemonade, may be given 
while the fever lasts. Convalescence is usually short, and 
patients quickly recover their digestive powers. But, at first, 
only soft, simply prepared, bland foods should be eaten. A 
normal diet can be resumed quickly. 

RELAPSING FEVER 

In relapsing fever the diet is that for acute febrile maladies. 
Nausea, vomiting, and, rarely, diarrhea may offer reasons for 
modifying the method and frequency of administering food 
rather than changing its character. Jaundice, which is a fre- 
quent complication, makes a liquid and chiefly a milk diet 
especially desirable. Convalescence is rapid, and patients 
usually can quickly be gotten on to soft and even solid food. 



CHAPTER III 
DIET IN INFECTIOUS DISEASES (Continued) 

Smallpox. Scarlet Fever. Measles. Erysipelas. Septicemia 
and Pyemia. Malaria. Tuberculosis. Influenza. Whooping- 
cough. Cerebrospinal Meningitis. Diphtheria. Rheumatism. 

SMALLPOX 

Anorexia, thirst, and vomiting are noteworthy symptoms at 
the onset of this malady, but vomiting is usually not of frequent 
occurrence. Cool drinks should be given; indeed, water should 
be administered freely in all stages of the disease, both because 
it adds to the comfort of the patient and because it will help 
to avert nephritis, which is an occasional complication. Febrile 
albuminuria is common; but milk or other nonalbuminous 
liquid foods will lessen or stop it. During the febrile stage a 
liquid diet, such as is usually prescribed in acute fevers, should 
be given — milk, broth, gruel, etc. Often the mouth and throat 
are so sore from the eruption that swallowing is difficult. Food 
must then be given in small portions at a time. Ice and ice- 
cream are often grateful to patients at this time. Sometimes 
swallowing is so painful that rectal alimentation must be 
resorted to. It should not be relied upon longer than is 
absolutely necessary, for when suppuration takes place upon 
the skin, prostration develops rapidly and is often very great. 
It is, therefore, necessary to give food by the mouth as steadily 
and in as large quantities as possible. Rectal alimentation 
must occasionally be utilized in order to help maintain strength 
when the stomach will not tolerate or digest food enough. 
Milk should be the staple article of diet. Gruels, weak tea, 
Mellin's food, farina, and similar articles may be employed for 
variety. If there is no albuminuria, or if it is only trifling and 
transitory, bouillon, broths, raw or soft-cooked eggs, custards, 

230 



SCARLET FEVER. 23 1 

and such dishes may also be used. If digestion is fairly good, 
as it is in mild cases, milk-toast, soft-boiled rice or oatmeal, 
corn-starch pudding, blanc mange, gelatin jellies, finely mashed 
potato with meat-juice squeezed upon it, may be given and 
will be relished. In the severe cases these articles may be 
given only during convalescence. 

SCARLET FEVER 

Vomiting is the rule at the onset of the malady, but is rarely 
troublesome afterward. During the few days of fever, cool 
drinks — water, lemonade, Seltzer, etc. — should be given freely. 
The food must be liquid. Milk is the best. It can be varied 
by gruels, oranges, stewed or baked apples, and stewed prunes. 
But while the fever ranges high, it is best to use only milk or 
gruels. These ought to be given every hour, in doses of from 
three to five ounces. 

When the throat is intensely sore, swallowing may become 
so distressing as to cause children to refuse food. Then rectal 
alimentation must be resorted to. Care should especially be 
taken that enough fluid is administered by rectum or hypo- 
dermically to maintain good elimination by the kidneys. 
Ice-cream can often be swallowed with comfort when fluids 
give pain. 

Such a diet should be prescribed as will avert nephritis. 
The latter occurs more frequently in scarlet fever than in any 
other eruptive disease. It usually shows itself in the second or 
third week of the malady. During the period of maximum 
pyrexia, albuminuria is common. It is rare, however, that 
nephritis develops at this time. Exposure to cold during the 
period of desquamation is a cause of nephritis, but it is probable 
that the complication is more frequently due to overeating or 
to unsuitable food. Jaccoud maintains that scarlatinal 
nephritis can almost always be averted by a rigorous milk diet, 
persevered in until after the third week. The kidneys are 
commonly in a pathologic state during pyrexia, but true 
nephritis generally dates from the period of desquamation, 
because the skin can then perform its functions so imperfectly. 
If at this time the diet contains a small amount of fluid and 



232 DIET IN INFECTIOUS DISEASES. 

considerable albuminous food, nephritis should be expected, 
because the substances to be eliminated by the kidneys will 
come to them in a concentrated form and be voided in con- 
centration. Highly nitrogenous food will impose still more 
work upon the kidneys. It is, therefore, not surprising that 
nephritis develops. Moreover, eating mixed foods heartily 
during fever, leads to their imperfect digestion and to their 
fermentation in the gastrointestinal tract, which produces 
abnormal products to be absorbed and eliminated by the 
kidneys and at the same time to irritate them. Milk, of all 
foods, is least likely to produce these irritating substances. 
Salt is also irritating to the kidneys. Therefore, it should not 
be added to food generously and foods containing much of it 
should not be eaten. The bowels must be emptied regularly 
and perfectly to prevent harmful fermentation in them. 
Since nephritis appears almost as often after mild scarlatina as 
after severe cases, great care in regard to diet must be taken in 
all cases during the first three weeks of the illness. 

Milk is the best food during this time. Kumiss, matzoon, 
ice-cream, and gruels may be employed for variety if a strict 
milk diet can not be maintained. Fruit and fruit juices also are 
permissable in moderation, but the soreness of the throat 
sometimes does not tolerate them. When convalescence 
is established, there may be added to the milk diet, oatmeal, 
soft-boiled rice, puddings of corn-starch, farina, and sago, with 
cream, milk-toast, cream toast, baked potato, stale bread with 
butter, or fruit jellies, baked apples, stewed apples, stewed 
prunes, and oranges. After the third week, fish, such as 
creamed codfish, oysters, or oyster or clam broth, squabs, and 
breast of chicken, and, later, the red meats, may successively 
be tried. A greater variety of simply cooked vegetables may 
also be used. Adults may have tea, coffee, and cocoa. 

During the first days of convalescence care must be taken 
that too much food and food of too varied character, be not 
taken. Children become extremely hungry, but their desire 
for quantity and variety cannot safely be satisfied. 

When, in spite of such care, inflammation of the kidney 
develops, the regimen must be that of nephritis rather than of 
scarlet fever. (See p. 353.) 



EMPIRIC DISEASES. 233 

MEASLES 

The diet of measles is that of acute febrile maladies in general. 
During the period of pyrexia, appetite and digestion are poor. 
Food at this time should consist of milk, milk preparations, 
broths, and gruels. Cool drinks, such as water, lemonade, 
orange-juice, Vichy, Seltzer, either plain or with fruit-juice, 
such as unfermented grape-juice, should be given freely. 

Nephritis is as rare a complication of measles as it is common 
in scarlet fever. In some epidemics, enteritis, with diarrhea, 
is common. Care must be taken not to give solid food too soon 
or to vary the food too early. 

During convalescence, or at its beginning, there is danger of 
an extension of the bronchial inflammation to the small tubes, 
and of bronchopneumonia. When these complications occur, 
dangerous prostration develops. Dyspnea, hebetude, and 
anorexia make feeding difficult. Digestion is slow and imper- 
fect, but food is necessary to combat the growing weakness. 
Liquid food must be given often and in moderate portions. 
For adults, coffee is often useful as a cardiac stimulant. 

During the febrile period of the illness, hand-fed infants 
should be given food oftener, and in a more dilute form, than 
usual, so that the stomach shall not be taxed while its functions 
are imperfectly maintained. 

When convalescence begins in older children, a more varied 
diet may at once be prescribed. Solid food and especially 
nitrogenous foods need not be withheld, as in cases of scarlatina. 
Exception to this rule should be made in the case of hemor- 
rhagic measles. This form of the malady is not only more 
severe, causing greater prostration, but is more liable to renal 
complications, such as nephritis, or, if not to inflammation of 
the kidneys, at least to renal incompetence. 

ERYSIPELAS 

In a majority of cases the malady is mild, produces a very 
moderate fever, and somewhat lessens appetite and the ability 
to digest food. The diet in such cases should consist of liquid 
and soft foods, given in moderate quantities, from four to six 
times daily. When the disease is accompanied by high tem- 
perature, delirium, or stupor, dry, parched lips and tongue, 



234 DIET IN INFECTIOUS DISEASES. 

food must be altogether fluid. It should consist, as in other 
febrile maladies, of milk, broths, gruels, and, sometimes, 
especially if the heart beats feebly, of coffee. In rare cases, 
most frequently in erysipelas of the head, the cervical glands 
enlarge and make swallowing difficult. A pharyngitis exists 
in these cases. Under such circumstances only liquid food can 
be swallowed, and in but small amounts at a time, and it may 
therefore occasionally be necessary to give nutritive enemata. 

In severe cases, food enough to maintain strength cannot 
be given, but enough can be fed to lessen the rapidity of the 
loss of flesh and strength. 

Erysipelas is one of the diseases in which water is specially 
needed to dilute noxious matters and aid in eliminating them 
through the kidneys. If liquids cannot be administered in 
sufficient quantity by the mouth, the therapeutic saline solution 
should be given by the rectum or hypodermically. Albumin- 
uria is common, even in mild cases of erysipelas, and nephritis, 
although of less frequent occurrence, is often observed. This 
complication is caused partly by toxines generated by the 
streptococci, which produce the disease, and partly by the 
products of fermentation in the gastrointestinal tract, as in 
scarlet fever. Therefore, as in that disease, regular and thor- 
ough emptying of the bowels and a milk diet, or one from which 
as little irritating or poisonous matter will be generated as is 
possible, is necessary to prevent or to combat albuminuria or 
nephritis. These complications can be prevented or mitigated 
in part, by maintaining good elimination by the kidneys, and 
nothing contributes so much to accomplish this as giving water 
and milk freely. 

During convalescence the same care must be exercised as in 
most acute fevers. A normal diet must be approached through 
soft and simply prepared foods. Recovery is so prompt in 
mild cases that a normal diet may be resumed almost as 
soon as fever is gone. The quantity of food taken should be 
moderate. 

SEPTICEMIA AND PYEMIA 
In these maladies appetite is diminished, digestion impaired, 
and general strength much lessened. It is essential, therefore, 



SEPTICEMIA. 235 

that as much food be given as possible to overcome loss of 
strength and to restore vigor, that it be as easily digested as 
possible, and sufficiently varied and dainty to tempt the appe- 
tite. These general dietetic principles are especially applicable 
in the chronic or prolonged cases. 

Anorexia, as well as great feebleness, makes feeding difficult 
in the severest cases. Such easily digested and assimilated 
food as milk, broths, gruels, and egg-nog, should be given in as 
large quantities as the patient can take and utilize. Often, 
however, food must also be given by the rectum. As in all 
other maladies in which mental hebetude exists at times, water 
should be given regularly and in sufficient amounts to keep the 
kidneys acting well. If enough fluid cannot be given by the 
mouth, it should be given by the rectum or beneath the skin. 
It is especially in these cases that hypodermoclysis has proved 
most useful. Physiologic salt solution introduced beneath the 
skin in considerable quantities provokes a copious flow of 
urine, which is often followed by the mitigation of all symptoms. 
As much as two or three pints of water may be introduced 
gradually in this manner. Less frequently, in cases of extreme 
danger, a vein is opened and an intravenous injection of 
physiologic salt solution is made. In a large majority of cases 
a pronounced fall of the temperature follows the copious 
diuresis that is thus produced. All the other general symptoms 
are also mitigated. Unfortunately, this improvement is often 
but transitory. 

In proportion as the malady is chronic, the necessity for 
forcing food increases. It must be given often. When, as 
happens in many cases, considerable remissions of temperature 
occur, food should be crowded upon the patient, but during the 
hours of pyrexia it should be given in small amounts and in 
forms that make it very easy to digest and to assimilate. 

If nephritis complicates a septic or pyemic malady, the diet 
must be modified accordingly. Traces of albumin in the urine 
or a few granular casts with or without albumin point to a 
pathologic state of the kidneys. The diet should then be 
confined to milk and gruels, with an abundance of water and a 
little fruit or fruit- juice. In all other ways care should be 
taken to avert nephritis. For instance, the bowels must be 



236 DIET IN INFECTIOUS DISEASES. 

emptied regularly and those foods eaten which will not tax the 
liver and kidneys to eliminate them after digestion and absorp- 
tion. Patients must be protected also from the ill effects of 
cold or dampness. 

During convalescence the diet must be that usually pre- 
scribed for patients recovering from infections, and for those 
who are much enfeebled. It should be more varied than in the 
earlier stage of the disease ; at first solids that are finely divided 
are the best to use, but soon the simplest kinds may be given 
without being divided before mastication. 

MALARIA 

Malaria of the intermittent type is so acute a malady that little 
need be said of its dietetic management. With the onset of a 
chill, vomiting sometimes occurs. During the period of pyrexia 
appetite is wanting or diminished. It is not necessary to give 
food on these days if a patient is strong. If he is feeble and 
food must be given, it should be in small amounts and of a 
liquid character. In the intervals, simply prepared foods of a 
solid or semisolid character may be eaten. 

During attacks of remittent fever liquid food must be given, 
as it is in typhoid, at stated intervals and in about the same 
amounts. Milk, egg and milk, broths, and gruels are the best 
nourishment. An egg lemonade is often grateful to the patient 
and nutritious. A little ice-cream is an agreeable addition to 
the foods usually prescribed. Orange-juice, grape-juice, 
lemonade, and similar acid beverages are agreeable. As in 
other febrile maladies, it is necessary to see that sufficient 
water and other fluids are taken. 

During convalescence, anemia and feebleness are noticeable, 
generally in proportion to the duration of the malady. The diet 
should be a generous one, in order to strengthen and to restore 
the blood to a healthy condition. The diet should be mixed, 
but rich in meats. If there has been any evidence of renal 
inactivity during the progress of the illness, water, or milk and 
water, should be prescribed in large amounts, so that nitrogen- 
ous waste may be removed rapidly and come to the kidneys 
well diluted. The treatment then should be the same as in 



MALARIA. 237 

scarlet fever and other infections in which the kidneys are 
involved. 

When there is malarial cachexia, the appetite is capricious 
or wanting; digestion is impaired; vomiting is provoked, and 
forms at times a distressing, because a persistent, symptom. 
These are conditions that are present, at times, in all severe 
anemias and in many chronic wasting diseases. 

If there are much nausea and vomiting, food must be given 
every hour or half-hour in doses of a spoonful. Even nutrient 
enemata may have to be resorted to for a time. 

When there is no vomiting, but digestion is enfeebled, food 
should be given with care, so that the stomach will not be 
overloaded. Milk, egg and milk, broths, gruels, custards, 
soft-cooked eggs, and meat-juice will constitute the staples. 
Sometimes a little finely divided and well-masticated meat will 
be well tolerated. Meat-juice and meat are especially indicated 
because of the anemia. Oysters, clams, and their broths are 
often agreeable to patients and wholesome. If the stomach 
tolerates solid foods, milk and cream toast, dry bread, and the 
simplest vegetables may be given. The fruits previously 
enumerated may be used, and also many of the stewed fruits, 
such as apples and prunes and baked apples. As rapidly as 
the patient's improved condition will permit, the diet should be 
made to approach a normal one. In many of these cases in 
which progress is toward a fatal termination rather than toward 
recovery, digestion gradually becomes more feeble, and feeding 
accordingly more difficult. 

TUBERCULOSIS 

The importance of diet in tuberculosis is universally admitted. 
No matter how good the climatic conditions under which a 
consumptive may live, he will not improve if he does not have 
suitable aliment. The prognosis of a given case must depend 
largely upon the ability of a patient to eat and to assimilate 
food. 

The object of dietetic treatment is to maintain strength and 
to develop resistance to the infection and to the spread of 
tuberculous lesions. 

If tuberculous patients are classified accordingly as their 



238 DIET IN INFECTIOUS DISEASES. 

power to digest and to assimilate food is impaired, they can be 
placed in three categories. One embraces those who have good 
appetite and ability to digest and to utilize foods. Another 
contains those whose need of food is increased because strength 
and endurance are being sapped by constant fever, but whose 
ability to digest and to appropriate nourishment to their needs 
is variously impaired. A third class includes the cases com- 
plicated by indigestion, the symptoms of which are poor appe- 
tite, a coated or, rarely, a raw, tongue, slight flatulence, con- 
stipation, continued loss of flesh and of strength. It is rare 
that pain, nausea, vomiting, and other symptoms of acute or 
subacute gastritis are observed. 

Patients belonging in the first category need little guidance 
as to their diet. They may be permitted to eat all kinds of 
food that they enjoy. They should, however, be counseled to 
preserve their good appetite and digestion by eating food that 
is simply prepared and least liable to check digestion or to 
ferment in stomach or bowels. 

They should be urged to eat as much as they can without 
overtaxing the organs of digestion. Just what this amount is, 
the physician should endeavor to ascertain. It is important to 
eat so as to increase weight. Fats, oils, and carbohydrates 
must be prescribed generously, but meat or albumins must not 
be neglected. These patients must be cautioned, the same as 
all others, not to swallow their sputa, which is often a cause of 
disturbed digestion, and sometimes of tuberculous infection 
of the intestines. When considerable quantities of mucus and 
mucopus are swallowed, they interfere mechanically with the 
digestion of food by enveloping it and separating it from the 
digesting juices. They also partly neutralize the acid gastric 
juice, or, when digestion is weak, they may do so completely. 
In these ways sputum when swallowed helps to produce indi- 
gestion or gastritis. 

For patients of the second and third categories food must be 
prescribed with care. Its character and quantity must be 
governed by the digestive capacity of each individual. As a 
rule, appetite is considerably diminished, and less food is taken 
than in health. Patients often say that their appetite and 
digestion are good because they do not experience subjective 



TUBERCULOSIS. 239 

symptoms of indigestion and they have eaten little for so long 
that they think it is natural. If they are carefully questioned 
as to the amount that they eat, its smallness will be demon- 
strated and they will modify their first statement by saying 
that it seems to be all that they need in their emaciated state. 
Others are painfully conscious of their poor appetite. This 
is especially true of those who suffer from chronic gastritis. 

Febrile patients should be fed as generously as possible. As 
the fever of tuberculosis is intermittent or remittent, the heart- 
iest meals can best be given during the hours of remission. 
When fever does not rise high or become manifest early in the 
day, noon is the best time for a hearty meal. If there is pyrexia 
at this hour, breakfast must be made the heaviest meal of the 
day. A glass of hot milk or cocoa, or coffee with an abundance 
of milk, should be given when a patient first awakes. Break- 
fast should come between seven and ten, when the morning 
coughing spell is over, if there is one. About three in the 
afternoon a glass of milk, a little meat-juice on cracker or 
bread, bouillon, chicken, or other broth, Mellin's food, malted 
milk, a custard, or egg lemonade should be taken. Supper 
should be comparatively light. At bedtime a glass of hot milk 
should be taken. When patients are feeble, they should be 
given a little food at two or three in the morning. As the 
patient's appetite is liable to be wanting or capricious at 
luncheon time, it is best to vary his menu for this meal as much 
as possible. Nor should the patient know what his lunch is 
to be, until it is brought to him. The quantity should be 
moderate, so that it will be quickly consumed. So long as 
digestion is fairly good, breakfast and dinner may consist of 
the foods usually eaten at those times. The patient is sure to 
eat sparingly. If he is permitted to eat as others do at these 
mealtimes, he will not grow restive under guidance, as he is 
inclined to do. At supper time, when his temperature is 
considerable, the simplest foods, and often soft and liquid 
foods with agreeable fruits, should be prescribed. 

When patients have gastritis, they must be studied with care 
as individuals, and food adapted to their various powers of 
digestion. Appetite is not a guide as to the ability of a patient 
to digest and assimilate food. D6bove showed this in his early 



240 DIET IN INFECTIOUS DISEASES. 

experiments with forced feeding of phthisical patients. He 
demonstrated that often a gain in weight will be made and 
maintained if sufficient food is forced into the stomach of 
patients who lack appetitie or suffer with anorexia. The 
appetite of such patients is so poor and so capricious that it is 
difficult to prevent slow, steady emaciation. Usually, under 
these circumstances, the quantity and functional power of 
gastric juice are lessened. Food is therefore best given in 
moderate quantities and in a soft or liquid condition. A rest of 
an hour should be taken before each of the three heartiest meals. 
Freedom from anxiety and care should be procured for these 
patients, if possible. A feeling of hopefulness should be 
encouraged, not of immediate recovery, but of possible, gradual, 
although slow, improvement. A change of scene, of nurses and 
attendants, often promotes better appetite and digestion. 

Oftentimes starches and sugars are not digested easily, while 
fats and oils are better managed. Eggs are usually tolerated, 
and should form an important element of diet. Scraped meat, 
raw or slightly cooked, is well digested by many; the usefulness 
of raw beef is attested by long experience, and Richet and 
Hericourt have claimed a special antituberculous virtue for 
the muscle-juice (zomotherapy) . Broths, gruels with milk and 
cream, fruits cooked and raw, meat-juices, jellies with bread, 
and buttermilk, cream toast, kumiss, matzoon, Mellin's food, 
malted milk, Robinson's barley with milk or cream, custards, 
eggs, raw, soft cooked, or in lemonade, ice-cream, and many 
more soft and liquid foods may be tried. If the patient's 
appetite will warrant it, occasionally a meat meal may be given 
him; for instance, a chop, or some steak or roast beef, or 
lamb, chicken breast, a squab, or some similar dainty, with a 
little potato, or peas, string-beans, boiled rice, or macaroni. 

The stomach should be washed by drafts of hot water before 
meals and by provoking, if need be, regular and free bowel 
movements. In this class of cases it is best to take a glass of 
warm milk about one hour before the fuller meals. This seems 
to prepare the stomach for greater work, and, strange to say, 
improves appetite. In all classes of cases, a glass of hot water 
about an hour before each of the three principal meals, and 
especially before breakfast, seems to do much good. 



TUBERCULOSIS. 241 

Debove introduced the pratice of gavage, or forced feeding — 

that is, the introduction into the stomach, through the stomach- 
tube, of considerable quantities of nourishment. This mode of 
feeding is indicated only when appetite is altogether lost or 
when there is much disgust for food. When no food or almost 
no food is eaten, forcible feeding may be resorted to three or four 
times daily. The most suitable foods for administration in this 
way are milk and its preparations, eggs, raw or with milk, 
meat extracts, meat-juices, meat powder, and gruels. If 
digestion is imperfect, these foods may be partly or wholly 
digested before they are given. If there is catarrh of the 
stomach and much mucus in it, this organ should be washed 
(lavage) before food is put into it. Excellent results have been 
obtained from this mode of treatment, so far as the addition 
of flesh and strength is concerned. Cough also often grows 
less, sweating at night ceases, and expectoration becomes less 
abundant. Frequently appetite improves for a time so that 
the use of the esophageal tube can be discontinued or needs to 
be resorted to only occasionally. Forced feeding has never 
become popular, for it is disagreeable to patients and usually 
of little ultimate utility, because, with rare exceptions, it is 
employed only when the hope of recovery is gone and the 
prospect of prolonging life is slight. 

To a degree, all feeding of tuberculous patients is forced ; for 
it is constantly the aim of the physician, during the periods 
when the lesions are developing rapidly, to give more food than 
the patient craves, and even more than is needed in health, 
if it can be utilized. Nevertheless care is necessary not to 
overtax the digestive power. 

It is my custom to urge all patients who are under weight 
and whose digestion is unimpaired to eat at regular mealtimes 
more than they crave : and at ten in the morning and three 
in the afternoon and at nine in the evening, two raw or soft- 
cooked eggs or if they can not take them comfortably, a mix- 
ture of egg and milk, or milk, or malted milk. Often it is 
best to vary these lunches by using sometimes egg and 
sometimes milk or milk mixtures : 

During periods of quiescence in the progress of the disease the 

16 



242 DIET IN INFECTIOUS DISEASES. 

aim should be to fatten and strengthen the patient so as to 
make him as resistant as possible to the malady. 

Various special diet cures have been much vaunted from 
time to time. The milk cure consists in the exclusive use of 
large quantites of milk for a few weeks. If a patient goes 
from home for the cure, and especially if he has more or less 
gastritis, he will almost always improve, but the gain is not 
permanent. It is like the gain so often noticed when a patient 
changes his residence, his nurse, or his doctor. His mental 
state has quite as much to do with his improvement as 
his diet. The same can be said of the kumiss cure. The 
results of the employment of kumiss at home are negative, ex- 
cept as it affords variety and is easily digested by weak stom- 
achs. But when the cure is taken on the steppes of Russia, 
where it originated, permanent good results are often reached. 
A change of scene and a favorable climate both play a part in 
effecting it. 

The grape cure also has been recommended for consumptives. 
It is probable that the climatic conditions and the changed 
environment have much to do with the seemingly good results 
of this treatment. The cure is practised at various places in 
the vineyard districts of Europe. I know of no place in Amer- 
ica where it is systematically carried out. One or two pounds 
of grapes are prescribed to be eaten daily. Moderate amounts 
are eaten at first, and the quantity is gradually increased. More 
than two pounds a day cannot safely be eaten, as appetite for 
other foods will lessen and the bowels will become loose, 
effects which must be avoided, as they cause loss of flesh and 
strength. A full mixed diet should be prescribed and the 
grapes should supplement it. The addition of one or two 
pounds of easily absorbed grape-sugar solution to an ordinary 
diet will often increase the weight of phthisical patient. It 
is believed by Bauer also to stimulate the mucous membrane 
of the throat which extends to the air-passages, and to assist the 
expectoration, etc. — in other words, favorably to influence the 
bronchial catarrh. The raw egg cure consists in administering 
between the regular meals from six to twelve raw eggs daily. 
They are so bland as to be unirritating to the stomach and 
are so nutritious as to insure almost always a rapid gain in 



TUBERCULOSIS. 243 

weight. They can be taken quickly with little more effort 
than a dose of medicine. They are swallowed easiest, directly 
from the broken shell or from a glass after the addition of a 
little salt, pepper and vinegar or lemon juice. An egg taken in 
this way is swallowed whole as an oyster might be bolted. 

The following diet-list will be found useful for those patients 
with good digestion who need to have food crowded upon them, 
in order to gain in weight and strength: 

On awakening : A cup of hot milk or of tea, coffee, or cocoa 
well diluted with cream or milk, or of beef tea, or of gruel. 
The hot milk is the best. The hot liquid food not only gives 
strength but makes coughing easier and the expectorate thinner 
and move easily dislodged. 

Breakfast, one to three hours later, at from seven to nine: 
Weak tea, coffee, or milk. One of the cereal food with rich 
cream and sugar. Bacon, fried hard, and a poached or boiled 
egg. Bread or toast and fruit or marmalade. This meal is 
preferably taken immediately after the morning coughing, un- 
less the patient falls to sleep for an hour or so, when it will 
follow the sleep. 

Bacon should form a staple breakfast dish if possible. Fish, 
sweetbreads, or minced meats may be taken instead of eggs. 

Luncheon at about eleven: A glass of milk, gruel, malted 
milk, Mellin's food, or a dish of Robinson's barley or of soft- 
boiled rice with cream. Milk is usually the best, for it is easily 
prepared and quickly taken. 

Dinner at from one to two: Soup, meat such as beef, mutton, 
lamb, or fowl. A variety of simply prepared and easily 
digested vegetables, like baked potatoes, peas, string- and wax- 
beans, corn, spinach, asparagus, and similar garden products. 
Salads with oil dressing are grateful to many patients, and the 
oil is a most useful food. Desserts should be simple. Those 
made or eaten with cream are especially good. Fruits are 
among the best. 

Luncheon at about four: A cup of broth, an egg lemonade, 
a dish of ice-cream, or a glass of milk. Bread or crackers may 
be eaten with these if desired. 

Tea at from six to seven: Fruits, fresh or preserved; bread 
and butter; some cereal food with cream, or cream or milk- 



244 D I ET IN INFECTIOUS DISEASES. 

toast. A small portion of meat. Milk or tea or cocoa weakened 
with milk if preferred. 

At bedtime: A glass of milk, hot or cold, as the patient 
prefers. 

Water may be taken as it is wanted. The easily digested fats, 
such as butter, cream, bacon, and olive oil, are especially to be 
recommended. The frequent use of foods on which they are 
freely eaten should be urged. Necessarily this regimen must 
be greatly modified for patients who have much fever or 
gastritis. 

The following is the dietary recommended by Dr. Weber: 

"At 7 o'clock or earlier, while still in bed, a cup of milk with a dessert 
or tablespoonful of cognac or with lime-water or with a small quantity 
of tea or cocoa, and a small piece of bread and butter. 

"At half past eight or nine o'clock, after dressing, breakfast of milk, 
with some stimulating addition, as tea, coffee, or cocoa, bread and 
butter or bacon, ham ,or fish. 

"At ii, a tumblerful of milk or kumiss, or sometimes a cup of broth 
or beef -tea, or a sandwich and a glass of wine. 

"At i or 1.30 a substantial meal of meat, poultry, fish, or game, with 
fresh vegetables, some light pudding or cooked fruit, and a glass of wine. 

"At 4 o'clock, a glass of milk or kumiss, or a cup of tea or coffee with 
much milk, and some bread and butter, or plain biscuit. 

"At 7 p. m., another substantial meal similar to that in the middle of 
the day. 

"At 9.30 or 10 p. m., on going to bed, a cup of milk, or bread and milk, 
or milk with some farinaceous food, as Hart's or Liebig's, or Nestle's, or 
Mellin's. At this time, if there be night-sweats, a tablespoonful of 
brandy is very useful. " 

At Dr. Brehmer's sanatorium at Gorbersdorf the following is a sample 
menu for one day : 

" Breakfast between 7 and 8 a. m., consisting of coffee, cocoa, tea, 
white or brown bread and butter, and a glass of milk. At ten o'clock 
luncheon, consisting of from one to two glasses of milk and bread and 
butter, or perhaps broth, egg, etc., and a glass of wine to finish with. 
At one o'clock, dinner of soup and three other courses, two of meat with 
vegetables, and one of pudding, with one or two glasses of wine. About 
7 p. m., supper of one or two courses, one cold and one hot, with vege- 
tables and one glass of wine; at 9 p. m., a glass of milk with two or three 
teaspoonfuls of cognac." 1 

At Nordrach three meals are given in the day: 

1 "Sanatoria for Consumptives," von Jaruntowsky, translated by E. Clifford Beale. 



TUBERCULOSIS. 245 

"Breakfast at 8 a. m., consists of coffee, bread and butter, and cold 
meat, such as ham, tongue, sausage, etc., and a half liter of milk. This 
after a time is reduced to a quarter liter, according to the patient's 
capacity and need for putting on flesh. Dinner at one o'clock consists 
of two hot courses of meat, or fish and meat, about six ounces being 
served to each patient, with plenty of potatoes and green vegetables, 
and sauces in which butter is the main ingredient. The third course 
may be pastry or farinaceous pudding, fruit, and ice-cream, with coffee 
and a half liter of milk. Supper at seven usually consists of one hot meat 
course, as at dinner, and one cold, as at breakfast, tea, and a half liter of 
milk. The last two meals must be taken under the supervision of the 
resident physician, and servants may not take away the plates until 
everything has been eaten. Roughly speaking, the patient eats about 
double the amount of food he desires." 1 

It is interesting to contrast with these menus that recom- 
mended by H. P. Loomis: 

"On awakening: Eight ounces of equal parts of milk and Seltzer, 
taken slowly through half an hour. 

"Breakfast: Oatmeal or cracked wheat with a little sugar and an 
abundance of cream, rare steak or loin chop with fat, soft-boiled or 
poached egg, cream toast, half pint of milk, small cup of coffee. 

"Lunch, 10 a. m. : Half pint of milk or small teacup of squeezed beef- 
juice with stale bread; 12 noon: Rest or sleep. 

"Midday meal, 12.30: Fish, broiled or stewed chicken, scraped meat 
ball, stale bread, and plenty of butter, baked apples and cream, two 
glasses of milk. 

"Lunch, 4 p. m. : Bottle kumiss, raw scraped beef sandwich, or goblet 
of milk; 5.30 p. m.: Rest or sleep. 

"Dinner, 6 p. m.: Substantial meat or fish soup, rare roast beef, or 
mutton, game, slice of stale bread, spinach, cauliflower, fresh vegetables 
in season (sparingly)." 

At the Loomis Sanitarium at Liberty, New York, the stronger 
patients are given the foods usually found upon the menu of a 
good hotel. For special cases, particularly if their ability to 
digest food is impaired, such a diet as the following is prescribed: 

"7 a. m. : Two eggs, soft boiled; two slices of buttered toast; one cup 
of coffee with milk, cream, and sugar. 

"9.30 a. m. : Kumiss, about ten ounces, and two slices of bread and 
butter. 

"12 noon: Lamb chops, steak, or chicken, mashed or baked potatoes, 
boiled rice in milk, toasted bread and butter. 

"3 p. m.: Same as at 9.30. 

"5.30 p. m.: Meat soup, with farina or the like in it; squab or other 

1 Fowler and Goodlee, " Diseases of the Lungs." 



246 DIET IN INFECTIOUS DISEASES. 

meat; thickened rice or some other pudding (custard); spinach, aspara- 
gus, or green peas; Bass ale or stout, half a tumblerful. 

"8.30 P. m.: Kumiss, crackers and butter, or oysters, or ale and 
crackers, or a sandwich and stout." 

Cod -liver oil must be regarded both as a food and a medicine. 
It is an important adjuvant to the diet of consumptives. 
When it is well tolerated, it should be used very steadily in 
tablespoonful doses three or four times daily. If it lessens 
appetite for other food, it should not be used, or should be taken 
in smaller amounts. It is best to begin its administration with 
teaspoonful doses and to increase the amount gradually. Only 
the clear and comparatively tasteless oils should be employed. 
When patients are especially fastidious in regard to its taste, 
it may be given as an emulsion, or, better still, in capsules. A 
pinch of salt or a bite of dry cracker will often remove its taste 
from the mouth. 

Alcoholic beverages are medicines rather than foods and must 
be prescribed as such. They are not now used with the same 
freedom as formerly. Fowler writes of them: "There is no 
evidence that the admittedly injurious effects of alcohol taken 
apart from food are not experienced in this disease, and we 
have frequently observed that patients who have previously 
been addicted to alcoholic excess suffer when attached by 
tuberculosis far more severely, chiefly from loss of appetite, 
inability to digest food, and a very irritable cough, than those 
who have led temperate lives." The routine use of alcoholics 
is not advisable and is not recommended by most of the recent 
writers on the subject. When they are used, they are pre- 
scribed as medicines to meet certain indications, such as a weak 
heart or enfeebled digestion with fever. 

Change of climate and of scene produces good effects which 
have already been referred to and are as notable in improvement 
of general nutrition as in improvement of the condition of 
the lungs. Living in a well-conducted sanitarium increases a 
patient's weight and strength because of good care, regular eating 
and sufficient food, and the hope inspired by seeing fellow patients 
who are recovering. These important aids in treating tubercu- 
losis must not be forgotten. 

What has been said in the foregoing pages while it is espe- 



INFLUENZA. 247 

cially applicable to those having pulmonary tuberculosis is 
applicable also to those having tuberculosis elsewhere. 

INFLUENZA 

In most instances the diet in influenza is the same as in other 
acute febrile diseases accompanied by loss of appetite and con- 
siderable or great prostration. During the acute progress of the 
malady food should be given often and in liquid form. Milk, 
kumiss, bouillon, broths, egg-nog, or egg and milk, must form 
the staples, especially the first of these. Patients should be 
encouraged to take from one to two quarts of these foods daily. 
It is best to give them every two or three hours and oftener 
in particularly severe cases. Occasionally cardiac weakness is 
so great that strong coffee will form a useful medicine, as well 
as a grateful stimulant. 

In those cases in which gastro -intestinal symptoms pre- 
dominate, the same dietetic problems confront one as in instances 
of gastroenteritis from other causes. Nausea and vomiting 
make the administration of food difficult. The weakness 
caused by a lack of food is often enhanced by diarrhea. This 
latter symptom makes rectal feeding impossible. Under these 
circumstances liquid food must be given in doses of a spoonful 
every half-hour. Usually larger quantities can be retained 
within twenty-four or forty-eight hours; it may then be given 
at intervals of one or one and one half-hour. Exceptionally, 
complete abstinence from food for twenty-four hours may be 
necessary to check the vomiting. Patient, careful feeding 
helps greatly to effect recovery. 

In many cases transient albuminuria is observed, which 
disappears when the fever subsides. In fewer cases nephritis 
complicates influenza. The urine should be examined fre- 
quently in all cases. If nephritis exists, a milk diet should be 
maintained rigorously, or only varied by permitting some 
farinaceous food and fruits. 

In all except the mildest cases physical weakness is very 
marked and rapidly developed. More nutritious foods, there- 
fore, should be prescribed as soon as possible. At first, beaten 
eggs may be added to milk or broth. Later, soft-cooked eggs 



248 DIET IN INFECTIOUS DISEASES. 

may be given, or oysters, scraped beef, pigeon, chicken breast, 
fish, and farinacous foods, with cream or milk. Often dry 
bread with fruit jellies is agreeable and permissible. Weak tea 
and coffee are also relished by many patients. One of the 
first vegetables that may safely be given is a mealy baked 
potato. Later, peas and wax-beans may be tried in small 
amounts tentatively. Oranges may be eaten at any time. 
During convalescence such fruits as baked or stewed apples, 
stewed prunes, and grapes may be eaten. Preserved fruits are 
also permissible if they are not too sweet. Peaches, apricots, 
and pears are to be preferred. 

During the febrile stage, water as well as liquid foods should 
be urged upon patients. Later, water ought to be given even 
more freely, as liquid foods are less used and solids are taken 
with greater freedom. 

When convalescence is protracted, feeding at prescribed 
times must be long continued. The appetite often needs 
whetting by tonics, or, if possible, by change of air. 

WHOOPING-COUGH 

It is often difficult to nourish children suffering from this 
malady, because of the vomiting that occurs so frequently 
with the paroxysms of coughing. In the severest cases almost 
everything taken is vomited. Of course, the child then grows 
pale, thin, and feeble; it may be, dangerously so. When 
vomiting is very frequent and persistent, resort must be had to 
nutritive enemata such as enemata of peptonized milk. In- 
unctions of oil, either of cod-liver oil or olive oil, may also be 
used as adjuvants to the enemata. In most cases food may be 
administered in part, if not wholly, by the mouth. Appetite is 
frequently capricious and much diminished. When it is, food 
should be administered in liquid form. In all cases care must be 
taken to avoid both overfilling the stomach and giving foods 
that are slow to digest. Except in the mildest cases or during 
convalescence food should be given often and in small quan- 
tities at a time. It should be kept ready, so that it can be 
given immediately after each paroxysm. A few spoonfuls at 
a time are all that can safely be given in the severer cases, in 



WHOOPING-COUGH. 249 

which it is frequently required at night as well as by day. The 
food-products to be preferred are milk, kumiss, milk and egg, 
bouillon, beef-tea, chicken broth, meat -juices, eggs soft-cooked, 
and custards, gruels, prepared foods, such as Mellin's, malted 
milk, and milk or cream toast. Since Jules Guyot advised 
coffee in whooping-cough it has frequently been prescribed 
for very young children as well as for adults. It is particularly 
useful when vomiting occurs frequently. One or two teaspoon- 
fuls of sweetened black coffee are given after each paroxysm. 
If a case is mild, almost any simply prepared food may be eaten. 
Care must be taken, however, not to overcrowd the stomach 
even under the most favorable circumstances. During con- 
valescence, flesh, strength, and color should be restored by a 
diet as nutritious and flesh-producing as the patient will 
tolerate. 



CEREBROSPINAL MENINGITIS 

During the stage of fever, digestion is impaired; therefore, 
only easily digested and assimilable food should be given. 
Liquids, such as milk, gruels, and broths, are the best. Nausea 
and vomiting make feeding difficult, or, for the time, im- 
possible. Rectal alimentation may have to be resorted to. 
It is rare that the rectum is tolerant, for diarrhea is the rule in 
such cases. Rectal feeding must also be employed during the 
periods of coma and convulsions. Huebner has advised forced 
feeding with the stomach-tube. So long, however, as a patient 
can swallow, it is best to give some food by the mouth. Often 
it can be given by the teaspoonful only, or by a medicine drop- 
per inserted between the nearly closed lips. If temperature is 
high, the food should be peptonized. It may be milk or broth, 
or both. If temperature is nearly normal, it is unnecessary 
to digest food before it is given. 

For mild cases a somewhat varied liquid diet should be pre- 
scribed, such as milk, kumiss, broth, meat-juice, custards of 
egg and milk, and soft-cooked eggs. 

In the rare protracted cases characterized by repeated re- 
missions and exacerbations the greatest pains should be taken 
during the former to administer nutritious food. A gradual 



250 DIET IN INFECTIOUS DISEASES. 

wasting is the rule. This must be controlled by giving as 
nutritious food in as large amounts as possible. 

During convalescence food is craved and can be given gener- 
ously five or six times daily. At first eggs, milk, and cream 
toast, cornstarch, blanc mange, rice, oatmeal, and the other 
cereals, scraped or minced meat, and oysters should form the 
menu. Later squab, breast of chicken, chop, steak, fish, jellies, 
fruit, the simple vegetables, and breads may be added to it. 
Since the discovery of a curative serum by Flexner the disease 
can be made milder and the expectation of recovery is much 
greater. 

DIPHTHERIA 

When prostration is extreme, which it often is because of in- 
toxication by the poisons of the malady, the maintenance of 
strength is a prime indication for treatment. It is an indication 
oftentimes difficult to meet, especially in children, because of 
vomiting, nausea, and pain in deglutition. Adults and older 
children endeavor to take food whenever it is possible in spite 
of these difficulties, but the amount eaten is always small. 
Because of the desirability of eliminating the toxins of the 
disease as rapidly as possible water or liquids should be given 
freely. When toxins are thus diluted, they are less liable to 
produce nephritis. Albuminuria is common. When present, 
the patient's diet must consist exclusively of milk, or at least, 
must not include other protein foods. 

If the case is a mild one, a normal diet is frequently continued 
or modified only by diminishing the amount eaten. In the 
severe cases, when there is not only disgust for food but great 
pain if it is swallowed, little children will not take it. Forced 
feeding by the nasal or esophageal tube has been advised under 
these circumstances. However, the danger of wounding the 
mucous membranes of the nose and esophagus is so great, and 
the danger of spreading the malady or making new gateways 
for the absorption of poisons is therefore so much increased, 
that the practice is one of questionable advantage. It is better 
to give what can be given through the mouth by a spoon or 
medicine dropper and supplement such feeding for the time 
by nutritive enemata. When swallowing is painful, ice-cream 



DIPHTHERIA. 25 1 

can often be taken more easily than other things, because it 
melts slowly in the mouth and trickles down the throat. Food 
must be liquid. If general symptoms, such as fever, feebleness, 
or dilirium, are especially noticeable, even though albuminuria 
does not exist, milk and gruels are the safest foods to use. 
When albumin is present in the urine, they must be used exclu- 
sively. Under other circumstances broths, meat-juices, cus- 
tards, egg-nog, and similar preparations are also useful. When- 
ever feeding is difficult because of anorexia rather than of dys- 
phagia, food should be varied as much as possible and offered 
as temptingly as possible. In all those cases in which water 
and food are taken in small amounts or not at all, I unhesitat- 
ingly urge the use of enemata, with hypodermic administration 
of therapeutic saline solution, to dilute the poisons in the blood 
and to favor their elimination by the kidneys. 

Semisolids, such as farinaceous foods, rice, arrow-root, Mel- 
lin's food, malted milk, milk and cream toast, or soft-cooked 
eggs, should be given whenever the patient can take them. 
During convalescence, food may be given generously and in 
greater variety. 

Pineapple -juice, which is capable of digesting proteins, has 
been given in this disease to dissolve the membrane in the 
pharynx. It is doubtful if, when swallowed, it stays long enough 
upon the mucous membrane of the pharynx to produce results. 

When the disease is recognized early and antitoxin is given at 
once, every case becomes a mild one and few problems of 
feeding are developed. Antitoxin should be given as early as 
possible. It has taken from the disease most of the difficult 
problems of feeding and prevents the dangerous complications 
which have in the past made feeding a problem of great 
importance. 

Intubation, which sometimes forms a part of successful treat- 
ment, necessitates care in feeding. The epiglottis does not 
always close the tube perfectly, and sometimes the larynx is 
not so easily lifted with the tube in it as it should be. Semi- 
solids have been found less likely to enter the tube than liquids. 
When liquids are given, they should be swallowed rapidly; 
afterward coughing will force out any fluid that may have 
entered the larynx and the intubation tube. Mush or thick 



252 DIET IN INFECTIOUS DISEASES. 

gruels, junket, eggs, and ice-cream are articles that may be 
administered with safety. A nursing infant succeeds best if it 
is so held on the mother's lap that its head hangs low and is 
tilted backward. 

To prevent the entrance of food into the trachea through the 
tube, an occasional mischance after intubation, the method of 
feeding first suggested by W. E. Casselberry has proved the 
best. He advises keeping the patient upon his back with head 
and shoulders lower than the body. Liquid food can then be 
taken from a nursing bottle, or through a tube or from an in- 
valid's drinking cup. It is important that the position of the 
body shall not be changed after drinking until several efforts 
to swallow have been made and time enough has elapsed for 
any liquid that may have gotten into the tube to gravitate back 
into the naso-pharynx and be swallowed or expectorated. 
Children can be held best in this position across a nurse's lap 
with the head and shoulders unsupported by the knees. It is 
not difficult for them to swallow and food will not enter the 
trachea. 

Usually the relief that intubation affords to dyspnea makes 
swallowing easier rather than more difficult. When a tube has 
been worn for a few days, the patient becomes accustomed to 
it and swallowing also is less troublesome. In some cases when 
dyspnea is not great, the tube may be removed for a few min- 
utes while the child is fed. This, however, necessitates the 
very frequent attendance of the physician. 

Postdiphtheric paralysis, which involves the pharynx and 
sometimes the esophagus, makes feeding very difficult. In rare 
instances a stomach-tube or catheter must be employed in order 
to conduct food into the stomach. Much more frequently 
enough food to maintain life can be swallowed, if it is taken in 
very small amounts and with sufficient slowness, although flesh 
and strength may wane. In the prolonged and most severe 
cases, nutritive enemata may be used as adjuvants to such food 
as can be given through the mouth. 

RHEUMATISM 

Acute articular rheumatism is undoubtedly an infectious 
disease. It is so well denned that there is little danger of 



RHEUMATISM. 253 

confusing it with other acute joint affections. We may say 
the same of the subacute form and of most of the milder 
grades of chronic rheumatism which are characterized by the 
attacks upon numerous joints in succession. Not infrequently, 
however, chronic rheumatism of sufficient duration and suffi- 
cient severity to produce deformed joints is confused with 
rheumatoid arthritis and other chronic deformities of joints. 
Necessarily, for successful treatment an accurate diagnosis must 
be made, and great care must therefore be taken in the examin- 
ation of all chronic articular affections. 

It is generally admitted to-day that acute articular rheuma- 
tism is an infectious malady, but through what channels infec- 
tion takes place, and what is the exact nature of the infectious 
matter, is not known. Formerly it was thought that rheuma- 
tism, like gout, was dependent upon a chemical disturbance of 
the blood or nutritional fluids of the body. Richardson taught 
that an excess of lactic acid in the blood was its cause ; but this 
has been completely disproved. Although it is now admitted 
that rheumatism is not due to any dietetic fault or fault in 
metabolism, it is a commonly observed fact that in a large pro- 
portion of cases the stomach is deranged prior to the onset of 
the rheumatism. Unquestionably, digestive disorders, par- 
ticularly those which lead to the production of sour stomach, 
predispose to it. They exert a similar influence upon gouty 
disorders. It is evident, therefore, that indigestion, when it 
exists, must be corrected, and in those individuals who are 
particularly prone to rheumatism, must be prevented. Most 
frequently the indigestion which predisposes to rheumatism 
causes the formation of an excess of gas in the stomach, also an 
excess of abnormal acids, and coincidently constipation. 

Rheumatism is frequently preceded by or its onset asso- 
ciated with tonsilitis usually of a mild type. It is also true 
that many who suffer from chronic rheumatism have chronic- 
ally infected tonsils. It is generally believed that infection 
takes place through these tissues. The fact that removal of 
tonsils and pharyngeal adenoids sometimes stops subacute 
and chronic rheumatism increases the possibility of the truth of 
this supposition. Infection also at times occurs or is persist- 
ently maintained by chronic suppuration in other obscure 



254 »IET IN INFECTIOUS DISEASES. 

places such as the sinuses about the face and the gall-bladder. 
To prevent attacks of rheumatism the possibility of infections 
from these places must be investigated. In the great majority 
of cases, however, the channel of infection cannot be found. 
Whether these suppurating disorders cause a true rheumatism 
or an arthritis which simulates it, has not been determined. 
Certainly these infections cannot be distinguished clinically 
from chronic rheumatism. 

Treatment 

Acute articular rheumatism is a febrile disease, and must be 
treated as the other fevers are. It is, however, necessary at 
the outset to cleanse the gastrointestinal tract as perfectly as 
possible because of the influence which imperfect digestion exerts 
upon the rheumatic trouble. This can be accomplished, in 
part by the administration of purges, preferably a saline; and 
in part by the prescription of proper food. It is equally neces- 
sary to wash from the blood any poisons that are provocative of 
the articular inflammations, which can be accomplished best 
by promoting as free elimination as possible by the kidneys, skin, 
and intestine. In the course of this trouble the skin usually 
acts freely, but an abundance of fluid should be furnished to 
the patient in order that diaphoresis may be made copious. 
Elimination by the intestine should be stimulated by the 
administration of cathartics, and the kidneys should be made 
to act more freely by liquid foods and copious drafts of water. 

The best diet during the stage of fever is a strict milk diet. 
It is usual for those suffering from this sickness to feel a disin- 
clination for food, and it is often necessary to urge nourishment 
upon them in order that they may get the requisite amount. 
Milk is usually taken with the least inconvenience by those who 
like it. Not infrequently, however, it causes a disagreeable 
taste in the mouth of patients with high temperatures. They 
crave acid drinks and cold water. The latter should be given 
them very freely. A little sodium bicarbonate may be added 
to it. This, however, although a useful medicine in the disease, 
is distasteful to most patients unless it is at least partly dis- 
guised, which can be done oftentimes by using a charged water, 



RHEUMATISM. 255 

such as Seltzer or effervescent Lithia water. Sometimes a 
little sodium bicarbonate can be mixed with lemonade without 
its being detected. Lemonade and water acidulated slightly 
with phosphoric acid make palatable drinks for rheumatic 
patients. 

Dr. Burney Yeo recommends that a nutritious beverage be 
prepared by mixing one pint of milk, one pint of boiled water, 
8 to 12 teaspoons (30 to 40 grams) of sodium bicarbonate, 2 to 
5 teaspoons (10 to 20 grams) of common salt; the whole to be 
cooled and a glassful to be administered every two hours during 
the day. This makes a beverage which combines nourishment 
with the alkali, so desirable for the patient suffering from this 
disease. Pateints who cannot take milk clear will often take 
it if it is diluted with a carbonized water. 

During the period of the fever, milk is particularly suitable, 
for it is one of the foods least likely to ferment in the stomach 
and intestines, and therefore least likely to make those organs 
foul. By promoting free diuresis it aids in the elimination of 
toxins. If patients are met with, however, who cannot 
tolerate milk in sufficient quantities to maintain life and 
strength, other liquid foods must be used as a substitute. The 
best of these are broths which are entirely free from fat, and 
gruels. An egg may be broken into the broths to advantage, 
adding very much to their nutritive powers and also making 
them more agreeable to the taste. Neither gruels nor broths, 
however, are comparable to milk in these cases ; for the gruels are 
apt to be slowly digested, and will often undergo fermentation, 
which causes a transformation of the sugar made from them into 
lactic acid, rendering the stomach unusually sour; and unless 
the broths are entirely free from fat they also are likely to be 
decomposed and to make the stomach sour. In broths alone 
there is not enough nutriment to maintain life. Many times, 
however, by a judicious combination of the two classes of food, 
and by the use of eggs in connection with them, and oftentimes 
by the employment of a little milk in addition, sufficient 
nourishment can be given to patients without deranging or 
overtaxing the digestive organs. 

In subacute cases, when there is little or no fever, a some- 
what more varied diet may be prescribed. Milk should, if 



256 DIET IN INFECTIOUS DISEASES. 

possible, form the basis of the food of such patients. In addi- 
tion to it, farinaceous articles may be used, but they should not 
be sweetened. Soft-boiled rice, arrow-root, cornmeal, oatmeal, 
cracked wheat, milk-toast, farinaceous puddings, blanc mange, 
custards, and broths may all be eaten by such patients, but 
never in large quantities at a time. If necessary, the number 
of meals per day may be increased. So much food should not 
be given at any one time as will tax the digestive and motor 
powers of the stomach, always limited in these cases. 

The same foods are suitable for those who are convalescing 
from attacks of acute articular rheumatism. 

In all cases of rheumatism, alcoholic beverages should be 
forbidden. It is universally admitted that they are detri- 
mental in this ailment. Tea, coffee, cocoa, and chocolate 
should also be excluded from the bill of fare. When the heart 
is weak, clear coffee, without sugar and cream may be given as 
a stimulant, but it should be used only in such cases. 

Albuminous foods must be used abstemiously both during 
convalescence and during the chronic stage of the disease. It 
may be necessary to prescribe them to a limited extent, espe- 
cially when patients are anemic, as is frequently the case after 
an attack of acute articular rheumatism. The albuminous foods 
best adapted to the use of patients suffering from rheumatism 
are eggs, fish, oysters, sweetbreads, and the white meat of 
pigeon and chicken. Such patients may also be permitted to 
take a variety of the simpler green vegetables; for instance, 
peas, string-beans, spinach, boiled celery, asparagus, lettuce, 
and a mealy baked potato or mashed potato. Very starchy 
vegetables and those that are most likely to ferment in the 
gastrointestinal canal should not be eaten. 

Of fruits, oranges can be eaten without harm. Many patients 
can eat a baked apple with comfort. It should not, however, 
be sweetened. The very acid fruits, such as strawberries, 
gooseberries, currants, and cherries, must be avoided. Preserves 
of all kinds are too sweet to be permitted to those who suffer 
from acute or subacute rheumatism, though small quantities 
can occasionally be taken as a relish by those whose joints are 
chronically stiffened by former attacks of rheumatism. If 
used too freely, however, they are liable to derange digestion 



RHEUMATISM. 257 

and to place the patient in a condition which makes him 
particularly susceptible to a renewed attack of his trouble. 

During the acute stage of the disease, food should be given 
every two or three hours. When convalescence is established, 
it may be given at gradually lengthening intervals and in 
somewhat larger amounts at a time. 

It is desirable in all cases to prescribe the copious use of 
water to promote as perfect elimination by the kidneys as 
possible. 

Persons suffering from acute or subacute rheumatism should 
be kept in large, well- ventilated rooms. They should be bathed 
daily with warm water, for they are likely to perspire so copi- 
ously that their clothing becomes saturated and their skin sour. 

Woolen clothing should be worn next to the skin continuously. 
So long as patients are confined to the bed they should He 
between woolen blankets. 

In order to avert injury to the heart, which so often occurs at 
this time because of the strain which is put upon it even by 
very moderate exercise, rest in bed must be enjoined in all 
cases of acute rheumatism until convalescence is thoroughly 
established. It is therefore best to keep patients in bed for at 
least two weeks after fever and pain have disappeared. 

Those who are prone to attacks of rheumatism should, if 
possible, avoid a changeable damp climate during the most 
inclement portions of the year. 

Recurrence is the rule among those who have suffered from 
acute articular rheumatism, each attack increasing the sus- 
ceptibility of patients to further recurrences, and each attack 
being likely to aggravate the cardiac lesions which are usually 
started early in the course of the disease. It is therefore of the 
utmost importance that every precaution be taken to avert 
repeated attacks. The utmost care should be used, first, to 
prevent digestive disorders, and if they occur, to correct them; 
second, to avoid exposure to great changes in temperature, 
particularly when they are associated with dampness. Those 
who are liable to rheumatism should live upon a dry soil, well 
drained, and in a climate where there is a maximum amount of 
sunshine. Woolen or silk should be worn next to the skin at 
all seasons of the year. Its thickness may be adapted to the 
17 



258 DIET IN INFECTIOUS DISEASES. 

temperature of the season. It is also well for patients who 
have made a successful recovery from an attack of rheumatism 
to train their skin to resist the effect of exposure to cold and 
dampness by taking daily a dry rub with a rough towel ; or, better 
still, a cold or tepid shower, followed by a brisk rub. In this 
way the blood-vessels of the skin can be taught to react to 
chilling, and the patient will become somewhat less susceptible 
to cold and dampness. 

Mineral springs are often resorted to advantageously by 
rheumatics, who are helped both by the drinking of such waters 
and by bathing in them. It does not seem probable that the 
chemical constituents of these mineral springs play a very im- 
portant part in effecting the relief which suffereres from rheuma- 
tism so often experience. Without doubt it is through the 
copious use of water, the dilution of the blood and tissue fluids, 
and the increased elimination of the soluble toxins by the 
various emunctories, particularly the kidneys and the skin, 
that the most good is accomplished. Those who are young, 
stout, and fairly vigorous often obtain good results by drinking 
the stronger saline waters which are purgatives and diuretics. 
If salines are taken by emaciated or very nervous patients, 
they are apt to increase the feebleness and the nervousness, and 
are, consequently, counterindicated. Hot water is to be 
preferred for such patients ; either the natural hot water to be 
found in many springs, or water that has been artificially heated. 
Hot water taken by the mouth, and hot baths are very useful in 
such cases. The hot springs possessing the most reputation in 
the United States are the Hot Springs of Arkansas, the Virginia 
Hot Springs, and the Glenwood Hot Springs of Colorado. In 
very many other localities springs of hot water are found 
which possess a local reputation for the cure of rheumatism. 
Those patients who suffer from rheumatism in its subacute 
form, with stiffness or some swelling of the joints, and slight or 
moderate atrophy of the muscles, are frequently greatly helped 
by drinking and bathing in sulphur waters, such as the waters 
at Richfield Springs in New York, and Mount Clemens in Michi- 
gan. Of late much of the good effect of treatment at mineral 
springs has been ascribed to the radio-activity of some of these 
waters, but that this plays any part in the successful treatment of 



VOMITING. 26l 

Some patients take hot foods more easily; others, cold ones. 
A little ice held in the mouth will sometimes benumb the sensi- 
bility of an inflamed throat and make swallowing easier. The 
simplest ice-cream, such as vanilla, can often be eaten when 
other things cannot. This is partly due to its benumbing effect 
on the throat, and partly to the fact that, as it melts slowly 
in the mouth, it can be swallowed in very small amounts at a 
time. I recall one case of paralysis in which life was maintained 
for several months by ice-cream. This could readily be taken 
by the patient, who found it difficult to swallow liquids and 
impossible to swallow solids. When the pharynx is inflamed, 
it may be sprayed with cocain and food can be eaten while 
anesthesia lasts. Orthoform in powder, lozenges, or emulsion, 
applied about fifteen minutes before feeding, will often relieve 
pain sufficiently to permit of a fair meal being taken. 

When the mouth or throat is too sore to make swallowing 
possible, a patient may be fed with an esophageal tube, or with 
a smaller one inserted through one nostril. The greatest dis- 
tress in swallowing is often experienced because of movements 
of the soft palate and fauces when they are inflamed. If a tube 
is introduced through one nostril, movement of these and the 
consequent pain can be avoided. In other cases rectal feeding 
is resorted to and relied upon entirely or in part for the main- 
tenance of life. Permanent intubation of the esophagus has 
been practised with success in some cases of stenosis, both of 
traumatic and of cancerous origin, and has enabled food to be 
swallowed for prolonged periods. When the esophagus or 
throat is impermeable, gastrostomy must be performed to make 
it possible to introduce food into the stomach through the wall 
of the abdomen. Food thus to be administered must be finely 
divided or in a liquid or semiliquid state. 

VOMITING 

Vomiting is a symptom that often prevents the utilization 
of food and makes it necessary to administer nourishment by 
the rectum, or at least in other ways than by the mouth. 

There is no one dietetic treatment for vomiting. Indeed, it 
is best, so long as it occurs with great frequency, to give no 



262 DIET IN DISEASES OF THE STOMACH. 

food until the cause of emesis has been removed. When this 
cannot be done quickly, nourishment must be given by the 
rectum, and possibly in very small amounts, one or two tea- 
spoonfuls at a time, by the mouth, at intervals that will prevent 
its accumulation in the stomach. 

It is important to recognize the cause of vomiting and to 
treat this. Overeating, eating unwholesome food or mixtures 
of food, gastritis, dyspepsia, gastric cancer, and ulcer are com- 
mon causes of the symptom. Vomiting that originates from 
indiscretions of diet is usually acute, quickly relieved by ab- 
stinence from food for a few hours, and preventable thereafter 
by avoiding such indiscretions. Rest for a time and careful 
dieting will often lessen vomiting or stop it entirely in the 
other conditions just mentioned. 

Emesis occurs also because of intense pain in abdominal 
organs, as when there is hepatic, renal, ovarian, or intestinal 
colic. It also arises reflexly, as in cases of pregnancy. It is 
due to lesions of the nervous system — as, for instance, in the 
gastric crisis of tabes and other nervous diseases. Mental de- 
pression or disgust excited by the sight or thought of uninviting 
food will sometimes provoke vomiting. It is frequently sec- 
ondary to other troubles — whooping-cough, scarlet fever, ane- 
mia, and many others. The modifications of dietetic treatment 
that this symptom necessitates are discussed fully in connection 
with each of these maladies. 

When there is a tendency to vomit, only the blandest foods 
and those that are not distasteful may be used. Highly spiced 
and seasoned foods must be avoided. Cold food is frequently 
retained better than hot — for instance, cold milk, ice-cream, or 
iced bouillon with a lemon in it. Liquids and soft food are 
usually retained better than solids. Occasionally there are 
exceptions to this, and very dry articles will remain in the 
stomach when liquids will not. Dry crackers, ginger snaps, 
even popcorn, have been known in these exceptional cases to be 
better retained than milk, broths, or custards. 

It frequently happens that a spoonful, or sometimes a few 
drops, of nourishment let fall into the mouth from a medicine 
dropper will be retained when a quarter or half a glass is 
rejected. 



DYSPEPSIAS. 263 

Bits of cracked ice allowed to melt slowly in the mouth often 
lessen the frequency of vomiting. Milk is generally better re- 
tained when lime-water, or Seltzer, Vichy, or other alkaline or 
sparkling water is added to it. Whey, kumiss, or matzoon will 
be better tolerated by other patients. Strong coffee taken in 
sips sometimes helps to settle the stomach. 

In all acute cases, abstinence from food for some hours, and 
the removal, when necessary, of offending material from the 
stomach, does more good than the administration of anything. 

Barley-water or beef-juice and the meat-juices of the shops 
given in very small quantities well diluted with water may serve 
a useful purpose when complete abstinence from food for hours 
or for days may be necessary, and yet, for various reasons be- 
yond the physician's control, cannot be enforced. 

When vomiting occurs during pregnancy, it is usually only 
in the morning or after eating too heartily. Sometimes it is 
well to omit or to postpone breakfast. At all events, this should 
be a small meal and consist of the simplest foods. Overeating 
and the eating of indigestible foods must be avoided. In some 
cases, when almost everything eaten is rejected, no kind or 
combination of food will stop the vomiting; then rectal alimen- 
tation must be resorted to and chiefly relied upon, although, 
as a rule, a little food can also be given by the mouth. Under 
these circumstances a patient must be kept in bed. It is neces- 
sary, in the most severe cases, to produce an abortion in order 
to prevent death from inanition. These are, fortunately, very 
rare. 

DYSPEPSIAS 

The word dyspepsia is used to designate those cases of indi- 
gestion that are due to functional instead of structural changes 
in the stomach. 

The functional derangements may consist in feeble peristalsis, 
exaggerated secretion of gastric juice, diminished secretion, or 
an entire absence of secretion. The cases may be acute, but 
are oftener chronic. Abnormal fermentation in the stomach, 
and the production thereby of irritating organic acids, is com- 
mon in dyspepsias and often finally causes inflammation in the 
organ. 



264 DIET IN DISEASES OF THE STOMACH. 

It will be noticed that the disturbances of motility and of 
the digestive secretions are the same in dyspepsia as in inflam- 
mation of the stomach ; so the dietetic treatment of both must 
be the same. It is, therefore, unnecessary to elaborate the 
treatment of those kinds of indigestion that are fully described 
under the headings of Acute and of Chronic Gastritis. It must, 
however, be remembered that in most cases there is a nervous 
basis for dyspepsia that must be considered in its treatment. 
This does not modify the regulation of diet, but it may affect 
the other features of the patient's treatment. 

When mental and nervous disturbances do not underlie dys- 
pepsia, bad habits of living, such as the taking of too little 
exercise, the excessive use of tobacco, and habitual indiscre- 
tions in eating, are fundamental causes of this ailment. It is 
also secondary to many diseases that cause general enfeeble- 
ment. For instance, chronic and severe anemias are common 
causes of dyspepsias and tuberculosis, and many other illnesses 
lessen the ability of patients to digest food and provoke func- 
tional indigestion. All such predisposing conditions must be 
removed or mitigated in order to effect a permanent relief of 
dyspepsia. 

Many individuals have naturally weak digestion and cannot 
eat heartily without suffering for it. In them acute and chronic 
imflammation of the stomach is easily provoked. They must 
be advised to eat only moderate amounts of food and the 
simplest kinds. 

ACUTE GASTRITIS 

Causes 

Food and drink have much to do with the causation of acute 
gastritis ; therefore their regulation is of importance to prevent 
the malady. A sensitive stomach, one peculiarly liable to 
acute inflammation, is inherited, or at least peculiar to certain 
families. Prolonged and severe anemia, cachexia, and febrile 
maladies predispose to gastritis, so that substances that ordi- 
narily would not irritate, will often provoke acute inflammation 
of the stomach in those afflicted by these maladies. 

Perfectly wholesome food may produce gastritis if taken in 



ACUTE GASTRITIS. 265 

excessively large quantities; this is oftenest observed in chil- 
dren and in those who are greatly weakened by other disease 
or by prolonged fasting. Or, if eaten so fast as to be imper- 
fectly chewed, which may be observed most frequently in aged 
persons who have few teeth and in those who eat hastily and 
carelessly, the bolted masses are too large or too tough for 
digestion, and therefore may act in the stomach as foreign 
bodies. Spoiled food also may produce gastritis, as when 
cheese is too old or milk contains irritating ptomains; when 
fruit is too ripe or spoiled, and meat too 'high.' Even food 
that is highly spiced may provoke inflammation if one's stom- 
ach is weak. 

Occasionally chemical irritants are causes of acute gastritis — 
strong acids or alkalies are sometimes swallowed by mistake or 
purposely, and cause acute inflammation of mouth, esophagus, 
and stomach. Gastritis produced in this way is usually intense 
and often fatal. It is rare that chemical preservatives added 
to food, such as boric acid and salicylic acid, cause gastritis, 
although they may do so when the stomach is unusually sensitive. 
However, there is no cause of this malady more common than 
alcoholic beverages. If they are taken in excess, and especially 
if they are taken on an empty stomach, they provoke it. They 
are properly classed as chemical irritants. 

Food or beverages swallowed when too hot may burn the 
gastric mucous membranes and excite in them acute inflamma- 
tion. Mechanical irritants, such as fish-bones, tacks, bits of 
glass, and similar solid articles, may cause gastritis. A blow 
upon the epigastrium has also been known to produce this 
malady, especially if the stomach is unusually sensitive for any 
reason. The idiosyncrasies of some persons may make a poison 
of food that is quite wholesome for other people. There are 
those who cannot eat eggs; others who cannot eat fish; a few 
who cannot eat strawberries — without having an attack of 
gastritis. 

The numerous causes of acute inflammation of the stomach 
show the need of care as to what food is eaten and how it is 
eaten, in order to prevent this disease; a care that those who 
are predisposed to it must especially exercise. 

Acute gastritis is of all grades, from the fatal burn made by 



266 DIET IN DISEASES OF THE STOMACH. 

a strong acid to the slight disturbance of secretion produced by 
excess of food in a vigorous man. In cases of the latter kinds 
the stomach will be distended, its churning movements will be 
imperfect or irregular, its juice unable to dissolve any but a 
small part of its contents, and digestion will, therefore, be slow 
and imperfect. The food will remain in the stomach long 
enough to spoil, and the products of its fermentation will irritate 
the mucous membrane still more. A few hours of discomfort 
are often all that is caused under these circumstances. 

Acute catarrhal inflammation of the stomach is accompanied 
by a diminished secretion of free hydrochloric acid and pepsin, 
and usually by an increased formation of mucus. The move- 
ments of the stomach may be lessened or imperfect; more 
frequently they are spasmodic, producing colic or pain, or 
reversed, producing vomiting. 

Treatment 

Nothing leads to a cure so certainly as abstinence from food 
for two days. The stomach is thus given a physiologic rest. 
In the mildest cases a little food may be given. In many others 
it need not be withheld more than twenty-four hours. It is 
often difficult to persuade patients, and even harder to persuade 
their friends, that it is safe to go without food for two days. 
That it is safe has been demonstrated so frequently that 
no proof need be cited. Experience has proven the utility of 
abstinence from food in gastritis beyond peradventure. In 
the severest cases even a longer time must elapse before the 
stomach is used for digestion, but food must, during this period 
of abstinence, be given in the form of rectal injections. But 
even in severe cases usually from a teaspoonful to a tablespoon- 
ful of peptonized milk may be given by the mouth at the end 
of the second day. These small quantities should be admin- 
istered every half-hour or hour. Although most patients are 
strong enough to go without food for one or two days without 
suffering dangerous weakness, it is not safe to starve for even 
a short time those who are already feeble. Such patients 
should be given nutritive enemata from the start. 

In severe cases vomiting is an early and constant symptom. 



ACUTE GASTRITIS. 267 

It can be lessened by feeding bits of ice so that a wineglassful 
will be taken in the course of an hour and a half or two hours. 
Cold, effervescent drinks, such as Seltzer water, also help to 
lessen it. A mustard plaster or a poultice placed on the epi- 
gastrium sometimes gives relief. 

Thirst is always increased and often intense. Bits of ice, or 
water taken in sips, will help to quench it. Care must be taken 
that too much be not swallowed as it will then provoke vomit- 
ing. Many times thirst can be lessened by rinsing the mouth 
frequently or by holding a mouthful of water for some moments. 
If water is made slightly acid by a little phosphoric or muriatic 
acid it will be grateful, and the temptation to drink large quan- 
tities will be lessened. When thirst is excessive and vomiting 
prevents drinking, water must be given by the rectum or by 
hypodermic injection. 

After the requisite period of abstinence, milk should be given : 
at first only one or two tablespoonfuls each hour, but if it is well 
tolerated, one-half or two-thirds of a glass may be given every 
two hours. Occasionally it is vomited in large curds. This 
may be prevented by giving it diluted with lime-water or Seltzer, 
or by boiling it and thickening it slightly with flour. It is 
rare, however, that it is undigested, if it is given at first in 
spoonful doses and only gradually in larger amounts. Even 
persons who do not like milk or with whom it does not agree can 
usually be taught to tolerate it when it is given in such small 
and slowly increasing doses. It is best to maintain a milk diet 
until convalescence is established. It may be fortified, as con- 
valescence approaches, by the addition of an egg or a little 
wheat flour. To most persons milk is most agreeable when 
taken cold. A few prefer it warm, and many can digest it best 
when it is warmed. Occasionally a person is found who prefers 
it if a little spice, such as nutmeg, or table salt and pepper, is 
added to it. These idiosyncrasies of taste may be gratified 
with safety. In mild cases bouillon may be given as well as 
milk, and its use may be begun early in convalescence. It 
may be strengthened with somatose, egg, or soft-boiled rice. 
Crackers or stale bread and meat -juices may be added early to 
the diet. Then such foods may be eaten as Mellin's, malted 
milk, Robinson's barley, sweet-breads, squab, eggs, chicken, 



268 DIET IN DISEASES OF THE STOMACH. 

scraped beef, minced ham, soft-boiled rice, tapioca, baked po- 
tato, fruit -jelly, baked or stewed apple, and prunes. 

Care must be taken during convalescence not to give food in 
too large quantities or food that is not easily digested, for the 
digestive power of the stomach is so lessened that it is easily 
overtaxed. If the food ferments, producing acetic, lactic, or 
butyric acids or other irritating substances, a relapse will be 
provoked. Such fermentation will surely occur if foods stay 
too long in the stomach. Patients should be cautioned to eat 
moderately and to eat only the simplest foods for three or four 
weeks after recovery, because the stomach is left unusually 
sensitive by this disease for some time. 

Tea is generally tolerated earlier than coffee, but neither 
should be permitted until the patient has recovered. When 
they are allowed, only a very small cup of either should be 
taken, and it should be weak. Alcoholic beverages must be 
forbidden. When they are the cause of gastritis, they should 
be forbidden permanently. It is true that dry champagne is 
sometimes administered with benefit in sips, to lessen vomiting. 

CHRONIC GASTRITIS 
Causes 

Chronic gastritis frequently grows out of acute inflammation 
of the stomach. The dietetic faults to which the acute disease 
can often be ascribed are not uncommonly the causes of chronic 
inflammation also; but it sometimes develops slowly and 
insidiously. 

Excess in eating is a common cause of chronic gastritis, espe- 
cially excess in eating rich, highly spiced foods. The constant 
use of strong alcoholics and the excessive use of the milder ones 
are also among the commonest causes of it. They lessen the 
muscular activity of the stomach and the vigor of the lym- 
phatic circulation in its walls and in the liver, gradually pro- 
ducing slow digestion and slow absorption. Abnormal fer- 
mentation of the contents of the stomach occurs almost always. 
All these factors combine to produce inflammation of the 
stomach. To prevent gastritis of this origin, two things are 
necessary: first, exercise so active as to insure deep breathing 



CHRONIC GASTRITIS. 269 

and a vigorous use of the abdominal and thoracic muscles, 
which will result in better peristalsis and a more vigorous circula- 
tion of lymph; secondly, regulation of the patient's diet. 

Not infrequently mental depression, business worries, family 
cares or sorrow, are causes of chronic gastritis, but they rarely 
are the only cause. As a rule, injudicious eating or a sedentary 
life is partly to blame. Still, the part that mental depression 
plays in provoking gastritis must be remembered, for often 
the removal of a patient from uncongenial or depressing sur- 
roundings, or from a business that entails constant anxiety 
and care, does more to effect a cure than any other remedial 
measure. 

Most diseases that produce long-continued debility predispose 
to chronic gastritis. Among these are chlorosis and other 
severe anemias, tuberculosis, malaria, and nephritis. The 
enumeration of these causes of chronic gastritis suggests their 
removal or avoidance, and therefore the prevention of the 
disease. 

The stomach's wall may be thickened, its mucous membrane 
may be thrown into deep folds or may be 'mammillated,' or 
it may be thin, the gastric glands atrophied and destroyed, 
so that they no longer perform their function. Such a 
pathologic classification is not so useful as a clinical one made 
by many authors who place cases of chronic gastritis in four 
groups, according to the functional power of the stomach, 
which is estimated by its power to do chemical work. The first 
group embraces those in which free hydrochloric acid exists 
in normal or increased amount. These are mostly cases in 
an early and transitory stage of chronic inflammation. For 
instance, the habitual and free use of alcoholics commonly pro- 
duces at first an excessive secretion of gastric juice. The second 
group is characterized by a formation of free hydrochloric 
acid in less than normal quantities. The third contains cases 
in which an excessive formation of mucus takes place. An 
abnormally copious secretion of mucus may occur in any of the 
other forms of the disease, but rarely in the first, and never 
to the extent that it may in the second. The fourth group is 
one of atrophic gastritis, when all gastric secretion, whether 
of free acids, pepsin, or mucus, ceases. 



270 DIET IN DISEASES OF THE STOMACH. 

While alcohol often provokes an excessive glandular activity 
at first, it soon leads to the production of an excess of mucus 
and to lessened secretions of gastric juice. Later, in the same 
individual, atrophic gastritis may follow. Thus one individual 
may at different times be placed in each of the foregoing 
groups of cases of chronic gastritis. It is not always true that 
a chronically inflamed stomach passes through these stages. 
The inflammation may, from the start, produce such changes 
in the functional power of the stomach as to place a given case 
in any category from the beginning. 

Treatment 

In many cases certain subjective symptoms enable physicians 
to determine whether there is a diminished secretion of gastric 
juice and whether an excessive formation of free hydrochloric 
acid is taking place. In other cases these distinctions can be 
made only by repeated chemical examinations of the stomach- 
contents. A diet must be carefully prescribed for each class of 
cases. The chemical character of the gastric juice and its 
quantity are the most important guides in prescribing a bill of 
fare. It is desirable, so far as possible, to select foods that 
are palatable to the patient, and for this reason to inquire 
minutely as to what he is accustomed to eat and what foods 
he especially likes. The method of cooking must also be con- 
sidered. In general it may be said that fried foods, pastries, 
and foods that are excessively sweet must be forbidden to all 
who suffer from gastric disorders. 

In cases of mild gastritis of either an acute or chronic type 
a radical change of foods will effect a cure even when little 
attention is paid to the exact needs of the patient. The reason 
for this is that when the patient ceases to eat his accustomed 
food, he will eat a smaller quantity. It must always be re- 
membered that when the stomach is impaired it is unable to 
digest as much as when strong. Many patients suffering from 
mild gastritis have an exaggerated appetite, and many others 
eat too much from habit. Those who are very ill frequently 
are given too much food by solicitous friends. The quantity 
that each patient is to eat must be prescribed with especial care. 
It can often be determined only by trial. 



CHRONIC GASTRITIS. 27 1 



Hyperchlorhydria 



In that group of cases in which free hydrochloric acid is found 
in excess the following symptoms are usually present to indicate 
it. The patient is generally thin and pale, though his appetite 
is good, perhaps excessively so ; his gastric distress, relieved for 
a time by eating, usually becomes intense two or three hours 
afterward; the abdominal walls are flaccid; the epigastrium is 
tender, but full and rounded by the distended stomach. Gas- 
tric peristalsis can frequently be seen through the abdominal 
wall. As a rule, the liver is enlarged and tender. Constipation 
exists in almost every case, and fecal accumulations can often 
be felt in the colon. In the stomach-contents free hydro- 
chloric acid and usually combined chlorids are increased. 
Secondary fermentation is the rule. This commonly produces 
lactic acid ; less frequently, acetic and butyric acids. Albumin- 
oids are imperfectly digested, remaining in a form coagulable by 
heat. Starches are also digested with difficulty. 

It is in this stage of gastritis that alkalis given in large doses 
some time after eating do good. It is rarely necessary to wash 
the stomach, except when there is considerable and prolonged 
stasis. A milk diet will afford the greatest relief. In the 
severest cases milk should be the exclusive diet. Later, as 
improvement takes place, the diet may be varied. In the 
milder cases milk should be used as the staple food, but one 
may begin with a diet such as is adapted to the second stage of 
the severe ones. When milk only is used, it should be taken 
warm, every two hours during the waking part of the day, one- 
half to two-thirds of a glass at a time. It is surer to digest 
easily if it is at first taken in small amounts, and sipped, not 
drunk rapidly. Those to whom milk is not palatable often 
take it easily when diluted with lime-water or Vichy. 

When improvement is established, the milk should be con- 
tinued, but the following and similar foods may gradually be 
added and given at the meal-times usual for one in health; 
gruels, Mellin's food, tapioca, farina, boiled rice, a milk soup 
with peas or other simple vegetable to flavor it, peas, spinach, 
a baked potato, bread, scraped meat, fish, oysters, broths, which 
may be strengthened advantageously with peptones, somatose, 



272 DIET IN DISEASES OF THE STOMACH. 

or egg; stewed prunes or a little marmalade. At first a very- 
small portion of these foods should be taken. If, on trial, no 
ill effects are felt, more generous portions may be eaten. As 
the diet at meal-times becomes more generous in quantity and 
variety, milk need not be taken so often. Instead of eight 
times daily, as at first, it may be taken at ten in the morning, 
at three in the afternoon, and at bedtime. It must especially 
be remembered that changes in diet should be made slowly, and 
that only small quantities of food should be eaten. An exclu- 
sive milk diet should always be maintained for a week or ten 
days. The additions just enumerated should be made gradu- 
ally during the ensuing ten to twenty days. No rich gravies or 
sauces should be used on fish or meat. When meat is first 
tried, it should be chewed slowly, the juice extracted, and the 
fiber and pulp rejected. When it is first to be swallowed, a 
little broiled steak should be scraped to a fine pulp or put 
through a meat-chopper. The meat should be broiled or 
boiled. All fried food should be forbidden. Bread may be 
permitted only in small amounts, and it must be stale. Pulled 
bread, Zwieback, and crackers are to be preferred. Bouillons 
and broths should be used sparingly, as they stimulate the 
secretion of gastric juice, but it is well to give them when con- 
valescence is well established. Alcoholic beverages are counter- 
indicated. Coffee and tea must be forbidden. Not until con- 
valescence is well begun may a little weak tea be permitted. 
Before this the patient's beverages should be milk and water 
only. When the patient is so nearly well that the amount of 
free hydrochloric acid in the stomach is normal and peristalsis 
is vigorous, the diet should be chiefly an albuminous one, 
varied by those vegetables that are not rich in starches. A 
little bread and fruit may also be allowed. In all these cases 
carefully made wheat bread is better than bread made from 
coarser flours, such as Graham and corn meal. 

Hypochlorhydria 

In many cases of chronic gastritis the first stage of increased 
acidity is of short duration, and in a very few cases may be 
wanting entirely. When free hydrochloric acid is much dimin- 
ished or entirely absent from the stomach, the following symp- 



CHRONIC GASTRITIS. 273 

toms are present: The patient may seem plump, or at least 
not excessively thin, although he eats little. Appetite is 
diminished; sometimes a disgust for food is felt. The stomach 
is not much distended except when abnormal fermentation in 
the stomach-contents is excessive. The liver remains normal, 
unless abnormal gastric fermentation produces irritation, 
provoking its congestion. Constipation may be habitual, 
but regular movements and even diarrhea are not uncommon. 
Gastric discomfort, sometimes acute pain, is felt immediately 
after meals. The pain disappears three or four hours later. 
If vomiting occurs, it happens immediately after meals. 
These symptoms are modified when acid fermentation is con- 
stant and excessive. The syndrome then presented by the 
patient more nearly resembles that of one in whom an excess 
of free hydrochloric acid is produced by the stomach. 

If the gastric juice is reduced only in quantity, the diet that 
has just been advised for those with an excess of hydrochloric 
acid in the stomach may be used, but bouillons, broths, meat, 
and spices, especially salt and pepper, will be found useful 
stimulants. Often salt and smoked meat carefully shredded 
or chopped are both grateful and best borne. They not only 
have sufficient taste to whet the patient's flagging appetite, 
but are also less likely to undergo abnormal fermentation than 
other foods. Creamed codfish and minced lean ham are the 
best of these foods. Condiments of a peppery kind are useful, 
for they stimulate a better secretion of gastric juice. 

The food should not be of a bulky character, nor be taken 
in other than moderate portions; and it is best to eat only 
three meals a day, so as to allow time for the digestion of each. 
Milk is not so useful as in the earlier stage of the malady, or 
when there is an excess of free hydrochloric acid in the stomach. 
It is too bulky, often very slowly digested, and therefore liable 
to lactic or butyric acid fermentation; at least it should not 
be used unless the stomach is intolerant of all food or much 
pain is experienced continously. It may, under these circum- 
stances, be given a tablespoonful at a time. 

When the digestive juice is only lessened, fish, eggs, meat- 
juice, minced meat, oysters, bouillons, and broths with salt 
and pepper freely added, are the best staples. These may 
18 



274 DIET IN DISEASES OF THE STOMACH. 

be varied by the addition, in small portions, of such vegetables as 
lettuce, spinach, tomatoes, peas, string-beans, and celery. 
Butter, cream, and olive oil in moderate amounts are also 
permitted, as are fruits in moderation, except the very acid 
ones, such as strawberries, currants, gooseberries, some cherries, 
and blackberries, and the sweetest, such as bananas, melons, 
and some grapes. Tea and coffee are allowable during con- 
valescence, but they are usually not well borne earlier. A 
sour wine or whisky much diluted with water will act as a con- 
diment and increase the formation of gastric juice, providing 
congestion is not great, inflammation active, or abnormal 
fermentation marked. Under any of these latter conditions — 
and one or another is usually present — they are counterindi- 
cated, as, on the one hand, they will increase congestion and 
inflammation, and, on the other, the wine will spoil and pro- 
duce acetic acid. Water is the best beverage. It is often 
most beneficial if it is taken hot, two teacupfuls at a time, a 
half-hour before meals. It will help to wash from the stomach 
the remnants of the last meal and to dislodge and remove any 
excess of mucus, leaving the stomach in the best possible 
condition for the reception of the next meal. Carbonized 
waters, such as plain soda, Vichy, Apollinaris, and effervescent 
natural or artificial lithia waters, are useful in mild cases, as 
the gas stimulates normal gastric secretions. Carlsbad, Marien- 
bad, Kissingen, and Homburg, among European waters, Sara- 
toga and West Baden among those of America, are useful when 
the bowels are constipated, though these waters undoubtedly 
accomplish more good if taken at the springs, when the climatic 
effects, the rest from business or home cares, the change of 
diet, the out-of-door life, and general regime of the spa play 
an important part in improving the patient's condition. Out- 
of-door life, regular, gentle exercise, and freedom from mental 
strain are conditions in many cases essential to successful 
treatment. 

Mucous Gastritis 

Mucous gastritis must be regarded as a complication of one 
of the two preceding forms. The diet adapted to individual 
cases will depend upon the functional activity of the stomach. 



CHRONIC GASTRITIS. 275 

In general, however, it can be said that when the stomach con- 
tains large amounts of mucus, the utmost pains should be 
taken to insure cleanness of the viscus. Lavage must be 
practised, and will contribute greatly to the relief of the patient. 
It is best to wash the stomach with an alkaline solution, as 
sodium bicarbonate, one dram to the pint of hot water. Food 
should be given in small amounts at a time, and preferably 
in liquid or powdered form or with powder in suspension in 
liquid. As to the kinds of food, one must be governed by the 
activity of the organ — that is, its power to form gastric juice 
and to do muscular work. 

Achlorhydria 

In the severest cases, when there is a complete lack of gastric 
juice and the churning movements of the stomach are very 
sluggish, that organ must be treated as a receptacle in which 
artificial digestion is to be carried on, rather than as a digesting 
structure. The food should be almost exclusively nitrogenous 
and enough hydrochloric acid and pepsin should be given to 
assist its digestion. When sugars and starches are administered, 
they ought to be in liquid form and of no greater bulk than 
the stomach is able to empty into the intestines before abnormal 
fermentation can occur in them. Milk may often be adminis- 
tered in small amounts, a wineglassf ul or so at a time ; likewise 
kumiss or matzoon, meat-juice, meat powder, somatose, 
scraped meat, creamed codfish, finely chopped lean ham, a little 
gruel of oatmeal or wheat flour, a custard made of egg and 
milk, a raw or soft-boiled egg, Mellin's food or malted milk, 
or Robinson's barley and granum. In extreme cases it may 
be necessary to resort to predigested foods. They may be 
given in part by the mouth and in part by the rectum. 

Exercise, active and passive, is essential because it is a 
stimulus to more active muscular effort. Hydrotherapy is 
often useful. Electricity will sometimes also prove efficacious 
in exciting gastric peristalsis. Constipation must be prevented 
by the use of laxatives, as diet alone will rarely relieve it. 
Buttermilk sometimes helps as a laxative. Stewed fruits and 
plums, prunes, dates, figs, pears, or apples will help when the 
stomach tolerates them. Honey, too, is a mild laxative for 



276 DIET IN DISEASES OF THE STOMACH. 

many persons and is less liable to undergo abnormal fer- 
mentation than most other sweets. 

Daily menus can be prepared for average cases of gastric 
incompetency and gastritis by selecting from the following list 
of foods. 

Drink four to eight glasses of water daily, milk, buttermilk, 
Vichy, Apollinaris. 

Rice (boiled soft), shredded biscuit, grape-nut, puddings 
of corn starch, arrow-root, custards, gelatin jellies, ice-cream. 

Breads, wheat (stale), toast, crackers. 

Potatoes (baked), beans (string or wax), peas, corn, spinach, 
lettuce, asparagus. 

Stewed fruit (especially prunes), fruit jelly, blueberries, 
grape-fruits, oranges, pineapple, grapes. 

Butter, olive oil. 

Eggs (soft cooked, boiled or poached, omelette. 

Meat, beef (steak, roast), lamb (chop, roast), sweet -breads, 
chicken, pigeon. 

Fish, whitefish, perch, trout, shad, oysters, clams. 

The patient should be instructed to avoid fried foods, rich 
gravies or sauces, candies and very sweet things : to eat only a 
small portion of each article, to eat slowly, and chew well. 

The following is a sample menu for a mild case or for one 
which is improving: 

Breakfast : One or two eggs and Zwieback or toast, with tea, 
coffee, or bouillon. In the milder cases, a cereal is permissible. 

Dinner: Bouillon with vegetables. Fish boiled, with a 
simple sauce, such as cream and egg. Roast beef, lamb, or 
broiled chicken. Baked potato, peas, string-beans, or corn. 
Stale bread. Lettuce salad with oil and vinegar dressing. 
Fresh fruits, or a custard, for dessert. 

Supper: Squab, breast of chicken, or a small portion of 
steak. Bread. A green vegetable. Stewed fruit, or rice or 
corn-starch pudding. 

Coffee or tea may be taken at two of these meals, but only a 
single cup should be permitted at a time. If there is much 
flatulence or sour stomach, both must be forbidden. To 
prevent flatulence and acid fermentation, only small amounts 
of food should be eaten at a time. The bowels should be 



GASTRIC DILATATION. 277 

emptied regularly, and the following foods should be eschewed : 
Cabbage, cauliflower, baked beans, beets, articles served with 
much oil, pork, preserved meat, game, fat fish, like salmon, 
shell-fish, cheese, fat foods or those that are fried or cooked with 
much fat or lard, wine, beer, cider, coffee with milk, choco- 
late and cocoa, pastries, pancakes, or other very sweet foods 
or articles eaten with syrup or much sugar. 

DILATED STOMACH 
Causes 

An excessively large stomach is not necessarily pathologic. 
So long as its muscular wall is capable of vigorous contractions 
and the organ empties itself of its contents in average time, 
it is not abnormal. A pathologic state of dilatation implies not 
only enlargement, but also imperfect muscular movements; 
therefore the long retention of food, and usually its very im- 
perfect digestion and absorption. The fermentation that almost 
of necessity arises under these conditions increases catarrhal 
inflammation and sometime causes it. It is an object of treat- 
ment, therefore, to relieve gastritis as well as enlargement and 
muscular atony. 

Pathologic dilatation of the stomach is due to two kinds of 
causes: First, to stenosis of the pylorus; second, to lack of 
muscular vigor without stenosis. The common causes of sten- 
osis of the pylorus are cancer, cicatrices, polypoid folds of the 
mucous membrane, hypertrophy of the sphincter, compression 
of the pylorus or duodenum by peritoneal adhesions, pancrea tit- 
tumors, and a dislocated right kidney. Some of these causes 
can be removed by the surgeon. The cases of gastric dilatation 
due to stenosis are rarely curable, but they can often be much 
improved. The usual causes of dilatation without stenosis arc 
excessive eating and drinking, gastritis, and gastric deformities 
that are most frequently the result of cicatrization following 
ulcers. All except the last cause are removable. 

Treatment 

Before dietetic or other treatment is begun the stomach 
must be perfectly emptied of its fermenting and often putrid 



278 DIET IN DISEASES OF THE STOMACH. 

contents. This is seldom accomplished thoroughly by vomit- 
ing, therefore lavage or stomach-washing is of the utmost 
importance in these cases. This is accomplished by passing 
a stomach tube through the mouth and esophagus by means 
of which water is introduced into the stomach and then si- 
phoned out. This process is repeated until the water returns 
clean, free from particles of food and mucus. At first it should 
be practised daily so that no large amount of food can accumu- 
late to distend the organ ; that its mucous membrane may be 
kept reasonably clean and free from mucus ; and that it may 
secrete and absorb in a natural way. The first indication for 
treatment in all these cases is to prevent an accumulation in 
the stomach. This can be accomplished in part by controlling 
the amount of food and drink that goes into it, but best of all 
by cleansing it at regular intervals. When the stomach con- 
tains much mucus, it is best cleansed by an alkaline water. 
Antiseptics also may at times be added advantageously to the 
water used for washing the stomach. Lavage is practised to-day 
exclusively with a soft-rubber siphon tube. 

In order to promote contraction of the stomach not only is 
it necessary to relieve this organ of any considerable load, but 
also to stimulate its muscular walls to contract and to empty 
the contents of the organ into the intestine. Massage is of 
great service in accomplishing this object. Electricity is also 
resorted to, although it cannot be relied upon to effect so much 
as massage will. The electrodes are usually placed upon the 
skin of the abdomen. Sometimes one is inserted into the 
stomach by means of the stomach-tube. Strychnin and laxa- 
tives are also important stimulants of the muscular walls of 
the stomach. 

The object of all dietetic regulations in this condition is also 
to prevent the accumulation of much food or fluid in the 
stomach, which, by its weight, might distend the organ; of 
course sufficient food must be given to maintain strength. 

In the severest cases not only will the stomach absorb very 
little of its contents, sometimes even secreting more fluid than 
is taken through the mouth, but the passage of food from the 
stomach into the duodenum is prevented by obstruction at 
the pylorus. Under such conditions one must rely for the 



GASTRIC DILATATION. 279 

maintenance of life upon rectal nutritive enemata, but usually 
some predigested food may be given by the mouth in moderate 
amounts. Some cases that seem hopeless will improve greatly 
under patient treatment. An instance in point occurred in 
my service at Mercy Hospital. It was a case of undoubted 
gastric cancer at the pylorus. The stomach was greatly dis- 
tended. The patient had become very anemic and too feeble 
to sit up in bed. Daily washings of the stomach, very careful 
feeding, gentle massage, and tonic and laxative medication 
produced slow improvement, which, at the end of ten weeks, 
was so great that soft foods could be eaten with comfort; the 
gastrectasis was entirely relieved, and so much strength had 
been gained that the patient could walk about the building 
without undue weariness. This was a case in which the pylorus 
was imperfectly obstructed, in which eating too much and 
abnormal fermentation of food produced great dilatation. The 
improvement lasted several months. Ultimately, however, 
the tumor grew so large as to cause greater obstruction at the 
pylorus, the old symptoms of gastrectasis returned, feebleness 
increased, and finally death ensued. 

While all clinicians agree that when a stomach is dilated the 
quantity of food eaten must be small, easily digested, and nutri- 
tious, they do not all agree as to its character or the frequency 
of its administration. As a matter of fact, a fixed regimen can- 
not be prescribed for all cases. The character of the food must 
vary somewhat according to the varying power of the stomach to 
digest, the more or less abundant secretion of free hydrochloric 
acid, and the different kinds of abnormal fermentation in the 
stomach-contents. In the details of the diet prescription, the 
physician must be guided as one would be in cases of chronic 
gastritis. 

When a patient is vigorous and his stomach will bear it, only 
solid food should be given and at long intervals, not oftener than 
three times daily, and sometimes only twice daily. Scraped 
meat or finely divided and well-chewed meat, fish, eggs (soft 
cooked and raw), Zwieback or pulled bread, a little lettuce, 
peas, asparagus, tomatoes, or spinach, as a relish should con- 
stitute the diet at first. As improvement takes place the 
quantity eaten at one time may be increased and the food 



280 DIET IN DISEASES OF THE STOMACH. 

varied. Dry bread, green vegetables, cereals, macaroni, orange- 
juice, stewed or baked apples or pears may be added to the 
foods already allowed. Liquids are particularly heavy, and 
therefore must be avoided when possible. A meat diet, such 
as has been described, creates thirst, wherefore patients should 
be permitted to drink a few swallows of water whenever they 
wish, but not to exceed from ten to fifteen ounces in twenty- 
four hours. They ought not to drink, however, while food is 
in their mouths, for they are then apt to wash it into the 
stomach before it is perfectly masticated. 

In another group of cases the extreme feebleness and gastric 
intolerance make it necessary to improve strength and flesh and 
to prevent vomiting if possible. In these cases rectal alimen- 
tation may have to be relied upon, but a little liquid or semi- 
liquid food may be given by the mouth with comfort to the 
patient — as, for instance, one or two tablespoonfuls of pepton- 
ized milk each hour. If this is well borne and does not accu- 
mulate unduly in the stomach, a larger amount may be given 
at slightly longer intervals. In cases of moderate severity a 
modicum of food may be given every two or three hours. For 
instance, at seven in the morning, from three to four ounces of 
water or weak tea, an ounce or an ounce and a half of dry bread, 
and an egg ; at half past nine, three or four ounces of beef tea or 
water, two ounces of stale bread and butter, or, if the patient's 
stomach is strong enough, three ounces of cold boiled ham or roast 
beef without fat, and half as much bread ; at twelve, five ounces 
of beefsteak or roast beef, three and a half ounces of soft-boiled 
rice, or, if preferred, one of mashed potatoes and two of peas; 
half as much fish and a small omelet might be substituted for 
the meat ; at half past two, from six to seven ounces of milk and 
two of bread, or one ounce of cream; at five, three ounces of 
cold lean meat and two ounces of crackers or stale bread, or three 
ounces of tea and two of toast ; at half past seven, three ounces of 
tea or water or milk, and two or three ounces of a cereal ; at bed- 
time, two or three ounces of milk or water. 

In general it can be said that when the stomach is dilated, 
fats, sugars, and more than a small amount of starches are not 
well borne, as they are especially liable to undergo abnormal 
fermentation. 



ULCER OF STOMACH. 28 1 

When the gastric juice is diminished in amount or wanting, 
hydrochloric acid and pepsin may be given advantageously. 
But no matter what the diet may be, as the first indication for 
treatment it should be remembered that food must be admin- 
istered in small amounts and that the stomach must not be 
allowed to become distended by it. 

GASTRIC ULCER 

The pain and distress that accompany this malady are due 
to the mechanical and chemical action of foods, and often to an 
excess of free hydrochloric acid. To give relief, the diet must 
be prescribed judiciously, and the excess of hydrochloric acid 
neutralized or reduced by dilution. 

Although gastric ulcer is seldom recognized unless there is 
hematemesis, its presence may be suspected when gastric pain 
is constantly excited by eating and the stomach persistently 
contains an excess of free hydrochloric acid. Under these 
circumstances gastric ulcer is likely to develop, if it does not 
already exist. Often occult blood can be found in the stools 
or in the contents of the stomach although it does not occur 
in quantities which make it visible. As a prophylactic measure 
an exclusive milk diet should be prescribed for one or two weeks. 
This will usually suffice to correct the trouble. When hyper- 
chlorhydria is present — and it exists in these cases to a greater 
or less degree — it may be necessary to pancreatize the milk 
or to render it alkaline in reaction by the addition of Vichy or 
of other appropriate water. Two-thirds milk and one-third 
Vichy water form a useful mixture. 

Most frequently gastric ulcer first comes under medical obser- 
vation after a hemorrhage. At this time food and fluids must 
be forbidden, for they may provoke the recurrence of bleeding. 
If the stomach is filled, the bleeding surface will be stretched 
and the clots dislodged, starting the hemorrhage again. When 
resting and empty, the stomach is in the best condition to 
encourage clotting of blood. Nor is it best to give enemata 
immediately after hematemesis, since they are apt to excite 
peristalsis in the stomach, as well as in the intestines. Still, 
if the hemorrhage has been profuse or prolonged, it may be 
necessary to maintain strength during the first few days or week 



282 DIET IN DISEASES OF THE STOMACH. 

by nutritive enemata, but they should be given infrequently. In 
most cases hemorrhage is not so profuse or continued that the 
drinking of water may not be permitted in small amounts at a 
time. To lessen thirst and to act as a styptic, a thin solution 
of gelatin can be given. It can be made more agreeable by 
acidulating it slightly with lemon -juice. After thirty-six or 
forty-eight hours of abstinence from food, a small amount of 
milk may be given, which will rarely do harm. The amount 
may be increased slowly. While such dietetic care is necessary 
to check gastric hemorrhage, it need hardly be said that rest 
in bed should also be insisted upon. An ice-bag upon the 
epigastrium will help, too. Styptics taken into the stomach 
and ergot administered hypodermically must be used in the 
severer cases. 

Hemorrhages are often slight and not repeated. A physician 
is sometimes not consulted until several days after their occur- 
rence. It is then possible to institute at once the regimen 
for gastric ulcer. This should consist of rest in bed for from 
two to eight weeks, except in the mildest cases, in which gentle 
exercise only and long hours of rest and sleep must be prescribed. 
In all cases milk should be the only food. If a patient comes 
under treatment at the time of hemorrhage from the stomach, I 
am accustomed to order, after forty-eight hours of abstinence 
from food, milk diluted with lime-water, administered in 
tablespoonful doses every half or three-quarters of an hour. 
As a rule, the quantity may be increased rapidly to half a glass- 
ful and given at intervals of every two hours. In two or three 
days a glassful may be taken at a time. To each glass of milk 
from two to four tablespoonfuls of lime-water or double the 
quantity of Vichy or Selters water should be added. If the 
exclusive milk diet is begun in this way, it is but seldom that 
large curds form in the stomach. The organ is gradually ha- 
bituated to this food, as it were, and learns to manage it well. 
On the other hand, if a glassful at a time is taken at the start, 
it is often curdled into large lumps and rejected. The vomiting 
increases the danger of renewed hemorrhage. In the mildest 
cases a quarter or a half glass of milk may be given at first 
every two hours. The milk may be taken either warm or cold, 
as preferred by the patient. 



ULCER OF STOMACH. 283 

The pain and distress of gastric ulcer lessen and cease after 
the milk diet is begun. This diet should be continued for 
two or three weeks in mild cases, and must sometimes be con- 
tinued more than two or three months in severe ones. 

Milk is to be preferred to other liquid foods because it does 
not excite the stomach to energetic muscular action as others 
do, is very easily digested, helps to neutralize the acids of the 
stomach, is locally unirritating, and nutritious withal. If the 
milk diet is begun as has just been advised, even most of those 
persons who cannot ordinarily digest milk easily find little diffi- 
culty in using it. To a few, indeed, it is so distasteful either 
from the start or after it has been used long, that other foods 
must be substituted for it in part or altogether. If it coagulates 
into large lumps of cheese, it may be necessary to peptonize it 
before it is drunk. Ice cream may be given to those persons 
who are especially prone to vomit. It is not a sufficient exclu- 
sive diet, but may be used exclusively for one or two days and 
afterward occasionally. Matzoon, kumiss, buttermilk, laban, 
and other milk preparations will prove nutritious and afford 
variety. During convalescence Mellin's food, malted milk, and 
similar liquid foods may be substituted for milk or used in 
addition to it when a variation of food is begun. If milk can- 
not be used at all, these foods, and, alternating with them, 
beef-juice chewed or expressed from meat, or such as is pre- 
pared by Wyeth and Valentine, may be substituted for it. 
Egg-albumen in water can also be taken. Somatose and sim- 
ilar preparations may be added to these foods with advantage. 

During convalescence, besides the foods just mentioned, a 
raw egg in milk, custard made of egg and milk, or scraped meat 
may be eaten, and, later, squab, the breast of chicken, oysters, 
fish, Zwieback, pulled bread, rice, tapioca, sago, farina, ver- 
micelli, and broths thickened with these farinaceous foods. A 
little orange- and lemon-juice may also be allowed, but it should 
be insisted that at first a few mouthfuls only of solid food be 
eaten. When a small meal is permissible, these foods should 
be taken at usual meal-times and a glass of milk at 10 a. m., 
3 p. m., and at bedtime. In order to prevent relapses, which 
are common, a light and very simple diet should be adhered 
to for several months. 



284 DIET IN DISEASES OF THE STOMACH. 

This regimen is usually much aided by a glass of hot water 
with Carlsbad sprudel salts the first thing in the morning. The 
salt is important to insure regular and full movements of the 
bowels, besides being useful to neutralize the acid of the stomach 
and to cleanse it. It is rarely necessary to give much medicine. 
Resorcin is a useful adjuvant to diet when there is much ab- 
normal gastric fermentation or nausea. 

GASTRIC CANCER 

A suitable management of diet adds greatly to the comfort 
and helps to prolong the life of those who have malignant 
growths in the stomach. 

It is not practicable to prescribe a fixed regimen in these 
cases. The diet must be adapted to the degree of obstruction 
that exists at the cardia or pylorus, to the motor power of the 
stomach, and to its ability to digest and absorb nourishment. 

When the tumor is at the cardia and produces a progressive 
interference with deglutition, liquid food only can be taken. 
The case must be watched closely to prevent distention of the 
esophagus above the stricture. As the obstruction becomes 
greater the amount of liquid food swallowed at a time must be 
lessened. 

When the tumor is at the pylorus, which is thus partly or 
wholly obstructed, care must be taken that the stomach does 
not become distended and that food does not remain in it long 
enough to undergo abnormal fermentation. In most instances 
gastrectasis exists when the patient first comes under treatment. 
The diet and care of the patient must then be directed toward 
a relief of gastric dilatation along the lines already described. 
Under the caption of Gastric Dilatation I have already alluded 
to the good results that can be obtained in such cases, and 
described the details of treatment. 

In malignant disease of the stomach there is, almost without 
exception, either a diminished formation of gastric juice or 
an entire absence of it. The character of food adapted to 
these cases is the same as for those of chronic gastritis in which 
there is atrophy of the glands and absence of free hydrochloric 
acid. 



CANCER OF STOMACH. 285 

The food should be small in amount and easy to digest; 
often it is even best that it should be partly digested before 
it is eaten. It should not be bulky or heavy. If the motor 
power of the stomach is good or may be restored, a variety of 
food may be given in small portions. Digestion will be per- 
formed fairly well in the duodenum. As the stomach cannot 
be expected to do its usual work of digesting and disintegrating 
the food, it is necessary to administer pepsin or papain and 
hydrochloric acid after albuminous, and taka-diastase or 
pancreatin after farinaceous, articles. It is also important 
that all food be finely divided when it is swallowed, or capable 
of quickly crumbling to pieces afterward. The stomach must 
be kept clean by daily or frequent lavage. By attention to 
these points the comfort and the strength of those in whom 
there is no obstruction or only moderate obstruction at the 
pylorus can be preserved. 

A patient recently under treatment had a moderately dis- 
tended stomach producing pain and discomfort which was from 
time to time temporarily relieved by vomiting. When about 
three ounces of peptonized milk were administered every two 
and one-half hours during the waking part of the day and his 
bowels were moved by enemata instead of laxatives the dis- 
tention and pain ceased. In a few days a few spoonfuls of 
gelatin jelly were given instead of one or two of the milk meals 
as a styptic and for variety. It soon became evident that he 
could take other things without discomfort, such as a soft 
cooked egg or meat juice or a little scraped meat, though these 
as often happens were not especially relished or craved, and 
a small saucer of cornstarch or tapioca or a little of crackers 
or stale bread instead of two or three of the portions of milk. 
As feeding in this case had to be kept up for weeks in small 
portions at the intervals named, it was a great comfort to the 
patient to have such foods as crackers which he could chew 
before swallowing. In this case, as in many others which I 
have observed, laxatives to relieve constipation produced pyloric 
contraction and painful peristalsis. In other cases not thus 
affected by them they are a help to prevent gastric distention. 

The best foods for the cases in which duodenal digestion 
must be relied upon are finely chopped meats, such as steak, 



286 DIET IN DISEASES OF THE STOMACH. 

roast beef, chicken, and squab, also soft-cooked and raw eggs, 
Zwieback, pulled bread, farina, starch, Mellin's food, Robinson's 
barley, and similar preparations. Milk is often well tolerated. 
In other cases it cannot be used because of the large clot of 
cheese into which it is transformed in the stomach. In such 
cases sour milk, buttermilk, matzoon, and kumiss are better 
than sweet milk. Often the addition of lime-water or of a 
little cooked flour will prevent the curdling of sweet milk. 

Antiseptics, and such digesters as papain, taka-diastase, 
pepsin, and hydrochloric acid are useful sometimes. 

In that large group of cases in which there is great, or practi- 
cally complete, obstruction at the pylorus, predigested foods 
only can be used with success, and what is not absorbed must 
be washed out at least once daily. To prolong life, rectal 
alimentation, which is particularly successful in these cases, 
must be employed. The slow but persistent loss of flesh and 
strength characteristic of the malady causes the tissues to adapt 
themselves to a meager supply of nourishment. Better results 
are, therefore, obtained from the seemingly minute quantity 
of food that is utilized than in most other maladies. Pancre- 
atinized milk, peptones, albumoses, somatose, and water 
may be given by the mouth. Occasionally, perhaps once or 
twice daily, the patient may be permitted to chew the juice 
out of meat or to take a little broth or fruit-juice. This will 
often satisfy a craving for the taste of food and partly com- 
pensate for the less agreeable foods upon which more depend- 
ence is placed. Preferably, they should be given an hour 
or two before the stomach is to be washed, in order that they 
may not remain in it long enough to spoil. 

The diet that has just been described and that has proved 
most useful in my hands is not recommended by Beneke. He 
argues that because of its chemical composition the morbid 
growth will be checked by diminishing the quantity of albumin- 
ous food and of phosphoric acid taken, and recommends there- 
fore the following diet : 

"Breakfast: A strong infusion of black tea with sugar and cream. 
A little bread with plenty of butter, and potatoes cooked in their skins, 
with butter. Cocoa may be substituted for tea. 



CANCER OF STOMACH. 287 

"Lunch : Fruit, raw or cooked. English biscuits, or a little bread and 
butter, and a glass of wine. 

"Dinner: Fruit soup or wine soup with sago or Indian corn meal, or 
potato soup. Not more than fifty grams of meat. Fresh minced pota- 
toes in the form of puree, mashed, or plain boiled. Any kind of vege- 
table roots. Stewed fruit. Apples or prunes with rice, or rice with 
wine. Salads and fruit ices. Light Moselle, Rhine wines, or cham- 
pagnes are allowed. Beer, however, is to be permitted only in small 
quantities on account of its large percentage of alkaline phosphates. 

"Afternoon: Black tea with sugar and cream, and a little bread and 
butter, and perhaps also some raw fruit and biscuit. 

"Supper: Soup as at dinner. Rice and fruit. Boiled potatoes with 
butter or potato salad. Small quantities of sardines in oil. Anchovies 
or fresh herrings. Buckwheat gruel with wine and sugar. Light wines." 

When malignant tumors develop in the stomach hematemesis 
is of frequent occurrence. It must be treated as in ulcer of 
the stomach. As in that malady, lavage is for a time coun- 
terindicated. It must be practised with great caution after 
hemorrhage, both because it is liable to excite fresh bleed- 
ing, and because there is danger of causing perforation of the 
stomach at the point of ulceration. 



CHAPTER V 

DIET IN DISEASES OF THE INTESTINES, LIVER, AND 

PERITONEUM 

Diarrhea. Diarrhea in Infants. Cholera Infantum. Entero- 
colitis. Chronic Enterocolitis. Appendicitis. Intestinal Ob- 
struction. Constipation. Catarrhal Jaundice. Obstructive Jaun- 
dice. Cholelithiasis. Cirrhosis of the Liver. Ascites. Peritonitis. 

DIARRHEA 
Causes 

Diarrhea is a symptom of several intestinal affections. 
Frequent, thin, stools, which characterize it, are due either to 
increased peristalsis, to excess of fluids in the intestines, or to 
both. Peristalsis is stimulated by irritating and undigested 
foods, such as spoiled or unripe fruits, and by chemical irritants, 
such as saline purgative waters, and toxic substances pro- 
duced by putrefaction of food. Diarrhea is frequently caused 
by drinking too much water, fermented liquor, or other fluids, 
as is often the case with persons working in extreme heat. 
More commonly the excess of fluid is chiefly due to excess of 
secretion. 

As a rule, irritating foods are rapidly expelled from the 
alimentary tract by diarrhea or by both diarrhea and vomiting. 
When this is not the case, it is best to provoke their prompt 
removal by laxatives, or irrigation, or both. If living fer- 
ments are the cause of chemical irritants, little or nothing is 
accomplished by any purgative except calomel, which possesses 
not only purgative, but also antiseptic, properties. 

One must be careful to abstain from drinking water or 
other fluids too freely, especially in hot weather, or when work 
is done in a hot place. But during the first twenty-four or 
thirty-six hours of a diarrhea it is often best to give water and 

288 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 289 

nothing else, and in small amounts, at short intervals, so that 
toxins generated in the stomach and intestinal canal and ab- 
sorbed into the blood will be diluted. Water will help also to 
eliminate them faster by the kidneys. The administration of 
water only, while the intestines are being rapidly emptied of 
their contents, furnishes a very imperfect culture-medium for 
the micro-organisms that may have generated the toxins pro- 
vocative of diarrhea. 

Treatment 

In acute attacks of considerable severity it is best to forbid all 
food for twenty-four or forty-eight hours, as it will undergo fer- 
mentation and thereby produce chemical irritants, or remain 
undigested and irritate stomach and bowels. During this 
period water only should be given, or a little barley-water, 
tapioca gruel, or egg-water. 

The indications for dietetic treatment are to give such foods as 
will produce as little residue as possible, and to diminish fer- 
mentation in stomach and bowels. To accomplish this, after 
twenty-four or forty-eight hours of abstinence, broths may be 
given either with or without soft-boiled rice, tapioca, sago, or 
cracker-crumbs. It is of importance that only small portions 
be taken at a time, because the intestinal residue will thus be 
limited and because the organs have a diminished power of 
digesting and absorbing. At first, a few teaspoonfuls should be 
given each hour, then a half cup, and later, at longer intervals, 
a cup. 

An exclusive milk diet is the best to start with, except in 
infancy or when it was the exclusive diet at the time of the onset 
of the trouble. Under the last condition, abstinence at first, 
and later a diet of egg- water and broth is best. When milk is 
not well borne, which happens sometimes with adults, broths 
must be substituted for it. If milk alone is used, it should be 
continued until all looseness of the bowels ceases. In some 
cases of diarrhea a change to a mixed and more generous diet 
must be made slowly. When it is safe to discontinue the milk 
diet, the following foods may gradually be substituted for it: 
Scraped meat, oysters, boiled rice with meat-juice, squab, 
breast of chicken, partridge, or quail, eggs, pur£e of peas, 
19 



290 DIARRHEA IN INFANTS. 

potatoes or beans, milk toast, macaroni, Zwieback, stale bread, 
weak tea, or cocoa. 

So long as there is danger of relapse, foods that contain much 
cellulose, such as the green vegetables, should be forbidden, 
likewise preserves, fruit, game that is 'high,' cheese, fat 
meats, rich sauces and gravies, or very sweet foods. 

In mild cases the dietetic restrictions need not be long main- 
tained, and changes may be made more rapidly. When 
frequent vomiting accompanies the diarrhea, the case must 
at first be treated as one of acute gastritis, and foods must 
be selected as for that disease. 

DIARRHEA IN INFANTS 
Causes 

This morbid condition is usually due to one or more of the 
following causes: overfeeding, too frequent and irregular 
feeding, feeding with improper and spoiled foods. It is much 
more frequent among bottle-fed than among breast-fed babies. 
Occasionally, illness of the mother will cause a simple diarrhea 
in her suckling. In most cases food other than milk, given 
before the child is sufficiently mature to digest it, is the cause. 
Milk that is not clean, or is old and on the verge of spoiling, also 
frequently provokes the illness. In other cases milk is con- 
taminated by passing through dirty nipples or by being held in 
dirty bottles or vessels. Nipples are sometimes dried with 
unclean cloths, or after sterilization handled with fingers that 
though apparently clean are bacterially contaminated. Some- 
times babies infect themselves by sucking their own dirty 
fingers, or wash-rags or handkerchiefs. Bacteria that grow in 
the milk or in the contents of the stomach, thereby giving rise 
to irritating chemical products, are undoubtedly the immedi- 
ate cause. 

Cleanliness of the child, the mother, their surroundings, the 
nursing-bottle, nipples, and utensils in which the baby's milk 
is kept and handled is a necessity if this disorder is to be 
prevented. The greatest care must be exercised to discover 
all possible sources of infection, although even with the most 
faithful watchfulness in this respect some slight cause of infec- 
tion is sometimes overlooked. 



DISEASES OF THE INTESTINES, LIVER AND PERITONEUM. 29 1 

Treatment 

When diarrhea exists, the best results are obtained by abstin- 
ence from food for twelve or twenty-four hours. The stomach 
and bowel should be cleansed by lavage if possible ; if not, by a 
mild mercurial or castor oil. Sterilized water, and in the mild- 
est cases a little egg-albumen in water or barley-water, may be 
given to quench thirst. Later, when the stools are less fre- 
quent and more natural, beef-juice, or thin mutton and chicken 
broth may be taken. Milk well diluted should be given after 
convalescence is established. Lime-water is the best diluent. 
Milk can often be modified advantageously. 

When excessive intestinal fermentation as well as diarrhea 
exists, a modification of the milk is essential. If the stools 
have a sour smell and are acid in nature, the percentage of sugar 
and fat should be lowered. If the odor is putrid, the albumin 
should be lessened. 

All foods ought to be given in small amounts and often until 
convalescence is well established. 

ENTEROCOLITIS, OR SUMMER DIARRHEA 
OF INFANTS 

Causes 

This ailment differs from simple diarrhea by more frequent 
defecation and stools containing streaks of blood and mucus. 
The child generally has more or less fever; at times a con- 
stantly high temperature, at other times a normal temperature. 
Micro-organisms are the common cause of this disease. The 
bacillus dysenterias of Shiga, is the cause of many cases and of 
most epidemics, but other bacteria frequently are causes of the 
same symptoms. Children are especially liable to be attacked 
during their second year, after they have partly or wholly left 
the breast, particularly in the summer season, when their food 
is more easily spoiled or contaminated by the growth of micro- 
organisms than at any other time. The heat of summer also 
makes the children less resistant, as is frequently shown by 
their rapid recovery when they are taken to the fresh air of the 
country, seaside, or lakeside. The ill effects of life in over- 



292 ENTEROCOLITIS. 

crowded buildings, and hot rooms, badly ventilated and dirty, 
are too well known to need amplification. In the first year of 
life infants are least liable to the disease if breast fed. When one 
that is bottle fed develops it, a change to the breast milk of the 
wet-nurse often effects a cure. The influence of hot weather in 
increasing the number of microbes in milk is readily understood. 
Moreover, the corollary is self evident that to prevent this 
disease milk must be handled so as to exclude bacteria from it 
as completely as possible. The utmost care must be taken 
with bootle-fed babies to maintain pure and fresh air about 
them and to insure absolute cleanliness of all vessels and uten- 
sils that come in contact with the milk to be given as food, as 
well as of the food itself. Sterilized or Pasteurized milk is 
often a prophylactic of value. 

Treatment 

When the disease makes its onset, the intestinal canal should 
be promptly cleansed by a laxative such as calomel, or, often 
better still, by castor oil. For twenty- four or forty-eight hours, 
sterilized water only should be given or a little rice-water or 
arrow-root, tapioca, or sago cooked with water. When given 
to older children, these drinks may be flavored with nutmeg, 
cloves, or cinnamon. This food should be sterile and fed from 
bottles or dishes scrupulously clean. In most cases it is neces- 
sary to abandon the use of milk for at least two or three days — 
often for a longer time. During this time it is best to give very 
little food — not more than a tablespoonful or two every one or 
two hours. Besides the rice or other farinaceous waters just 
mentioned, a little beef-tea or veal or mutton broth may be 
given. Egg-albumen stirred into water also may be used. 
Children one or two years old can take the cereal waters best, 
and after the first days, a somewhat thicker gruel. 

As a rule, milk cannot be tolerated, often because the casein 
in it is not well digested. Many times a modified milk will 
obviate this difficulty. The protein in it should be reduced to 
2 or 1 per cent, or less. It is also best to lessen somewhat the 
percentage of fat and sugar. When improvement begins and 
it seems necessary to give more nourishing food, a modified 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 293 

milk containing 3 per cent, of fat, 4 or 5 of sugar, and 2 or 3 of 
protein may be employed. The mixture should be made 
slightly alkaline by the addition of lime-water. As digestion 
becomes well established the ingredients of the milk may be 
made to approach nearer and nearer to the normal proportion 
of cow's milk or mother's milk to which the child has been 
accustomed. 

There are also numerous patients who cannot tolerate the 
fats but who can digest casein. Skim milk and butter milk 
often prove to be especially adapted to their needs. It is 
probable that the presence of micro-organisms in excessively 
large numbers in cream is the cause of the enteritis in many 
cases or at least aggravates it. Skim milk containing relatively 
so small a number is therefore less harmful and buttermilk full 
of the lactic acid ferment checks the growth of other organisms. 
Although these bacteriologic phenomena account for the 
harmfulness to many individuals of milk rich in fat there are 
others in whom the ability to digest fat is lessened. 

Flushing the colon with sterile water is of great importance. 
It should be done once or twice daily, and in some cases even 
oftener. A large quantity of water should be used so that the 
colon will be well cleansed, at least in the lower parts. 

It is a help to give such children a change of air, especially to 
get them upon the water, where fresh, clean, invigorating air 
will blow over them. Anodynes, antiseptics, astringents, and 
stimulants have their place in the treatment, but will surely 
fail unless hygienic and dietetic rules also are followed. 

CHOLERA INFANTUM 

This is the most severe and fatal of the acute intestinal 
diarrheas of infants. It is characterized by excessive vomiting 
and purging. The stools are thin, watery, and often copious, 
rapidly causing great prostration and even collapse. 

The indications for treatment are to remove the cause of intox- 
ication, to restore to the child the water lost by vomiting and 
purging, and to maintain the patient's strength. The cause of 
cholera infantum is the same as of the summer diarrhea of 
infants. That tyrotoxicon can cause it is well understood, 



294 CHOLERA INFANTUM. 

but that all cases have a common origin has not yet been deter- 
mined. Possibly, in some instances, an unusually virulent 
condition of micro-organisms normally found in the intestines 
gives rise to the syndrome. 

To cleanse the digestive tract, recourse must be had to 
lavage of the stomach and colon with sterile water. If the 
child is in a condition of collapse, stomach-washing may be 
injudicious, but flushing of the colon with hot sterile salt 
solution is of great value. All food should be withheld, only 
sterilized water being given by the stomach. It is most grate- 
ful when it is cold. The flushing of the colon must be repeated 
frequently, three or four times and sometimes oftener during 
the first days of the illness. This helps to cleanse the intestine 
and to restore by absorption to the blood some of the fluid that 
has been lost, to soothe the intestine, and to warm the little 
patient's body. 

When the loss of fluid has been excessive and cannot be 
replaced by natural channels because of frequent vomiting, 
water must be administered subcutaneously. A solution of 
seven parts of common salt in iooo is to be preferred for this 
injection. It must be made sterile and injected with anti- 
septic precautions. 

Food should be withheld until improvement in the gastro- 
intestinal symptoms is manifest. It is often difficult to re- 
strain parents and nurses from feeding a child too soon. It is 
best to wait twelve or fifteen hours after vomiting has ceased 
before beginning to give food. At first a teaspoonful of rice- 
water or albumen water should be given every half-hour. If 
this is well borne, it may be given in larger amounts at a time. 
Later, small doses of diluted milk may be given, or, better, of 
peptonized milk or modified milk, such as has just been recom- 
mended in enterocolitis. Many prefer to give weak broths for 
a day or two before they try milk; but all food should be given 
at first in quantities of a teaspoonful at frequent intervals. 
There is danger of giving too much while the digestive organs 
are weak and incapable of much functional activity. As in 
other forms of diarrhea, the change to a varied diet must be 
made very gradually. 

That this disease may best be treated amid pure, fresh air, 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 295 

and that every precaution must be taken to maintain cleanli- 
ness of the child is self-evident. The same advice as to change 
of air applies to these cases as to those of enterocolitis. 

CHRONIC ENTEROCOLITIS 

Adults suffering from chronic enterocolitis should be kept 
upon a milk diet for several weeks. Fats and starches prove 
especially indigestible. Therefore, at first, farinaceous food 
must be withheld, or, if used at all, must be given sparingly. 
Some patients cannot tolerate a milk diet because the fat that 
it contains is not well digested and the sugar ferments. If it 
is employed, the result is increased discomfort and often more 
frequent stools. Milk is sometimes made more digestible and 
suitable for use by skimming or by diminishing its percentage 
of both cream and sugar. If it is pancreatinized, it also be- 
comes more tolerable to the diseased and inactive organs. 

When milk is not well digested and assimilated, the best 
results are gotten from an almost exclusively albuminous diet. 
Under such circumstances meat-juice and broths may be given, 
also scraped meat, beef meal, beef peptonoids, and somatose, 
albumen-water, and often raw, soft-boiled, or poached eggs, 
and sometimes egg lemonade. Usually Zwieback or pulled 
bread in small quantities is harmless and grateful. In mild 
cases stale bread may be permitted, and a small quantity of 
some cereal that does not contain wheat husks or indigestible 
matter. Soft-boiled rice, farina, and tapioca are the best of 
these. They must also be given if emaciation increases when 
an albuminous diet is used. Still, a strictly albuminous diet is 
not suitable for prolonged use nor is it often long needed. Just 
as milk is counterindicated when it sours, so is meat when it 
putrefies and makes fetid stools. 

When improvement begins and the use of the simplest cereals 
has been shown to be possible, such articles of food as these may 
be tried with caution: minced beef, raw oysters, soft-cooked 
or raw eggs, boiled or broiled fish or creamed codfish, squab, 
breast of chicken, crackers, bread and milk, bread and butter, 
blanc mange, custards, and wine jellies. 

It must not be forgotten, in these chronic cases as well as in 



296 CHRONIC ENTEROCOLITIS. 

the acute, that there is great danger of overfeeding. Relapses 
are extremely common and usually due to overfeeding or 
improper food. 

When diarrhea seems thoroughly checked, such vegetables 
as baked potatoes, asparagus, spinach, stewed celery, and 
cauliflower may be tried. The following foods should be 
avoided: rich milk, green vegetables, raw acid fruits, dried 
fruits, nuts, shell-fish, pork, veal, foods prepared with rich 
gravies or very sweet sauces, coarse breads, pastries, and 
desserts in general. 

If constipation follows diarrhea, it should be relieved, when 
possible, by massage and active exercise and by drinking water 
freely, especially before breakfast. 

Chronic diarrhea in infants must be treated at first just as is 
the diarrhea of adults. Modified milk is especially useful. It 
is usually necessary to diminish the proteins and often also the 
fat and the sugar. Such a formula as this will generally agree 
well: Fat, 3 per cent.; sugar, 4; proteins, 1. To this lime-water 
must be added. The percentage of fats may be first increased, 
then the sugar, and last the proteins. When acid fermentation 
of the cream and sugar is considerable, producing sour stools 
and lumps of white, undigested fat (commonly called curds) 
in them, the percentage of cream and sugar must be lessened 
more than has been indicated. Modified milk may sometimes 
be strengthened advantageously by plasmon or somatose. But 
when putrid fermentation predominates, the percentage of 
proteins must be reduced. Under these circumstances pepton- 
ized milk often proves most useful. 

It is occasionally necessary, as in acute cases, to discontinue 
the use of milk. Beef broth may be employed as a substitute, 
but not for long, as it often increases the number of bowel 
movements if it is used exclusively for many days. Infants 
will sometimes improve on an exclusive diet of albumen- water. 
It is rarely necessary to use it exclusively for more than a few 
days. 

Sugars, starches, and fats are likely to disagree with these 
patients. Not infrequently a little cod-liver oil will be tolerated 
by babies when other fats are not. Inunctions of oil are often 
employed. A little is absorbed and assimilated in this way, and 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 297 

the massage of trunk and extremities necessitated by the rub- 
bing helps also, but the abdomen is often too tender to permit 
of its manipulation. 

During the first eighteen or twenty months of infancy the 
aim is, at first, to increase the quantity of nourishment given as 
improvement takes place, and later to get the patient little by 
little upon a milk and farinaceous diet such as is adapted to 
its age. 

In the case of chronic enterocolitis, acute exacerbations are 
not uncommon. The dietetic and hygienic rules already pre- 
scribed for acute cases must then be enforced. 

Water may usually be given as the patients desire it. When 
bowel movements are frequent and copious, enough should 
be allowed to allay thirst, but always in small quantities at a 
time. 

Life in fresh, invigorating air does as much good in chronic 
cases as in acute — as much good to adults as to infants. It is 
best to protect the abdomen with a woolen band. When 
health is restored, a patient should accustom himself to a cold 
morning bath and brisk rub, which will render him less sensi- 
tive to sudden falls in temperature and to cold drafts. 

In mucous disease or membranous enteritis the diet and regi- 
men must be the same as for chronic enterocolitis and its acute 
exacerbations. Frequently all food must be prohibited for a 
few hours. If the stools contain fat lumps or undigested curds, 
milk should no longer be given or it must be modified. Broths 
may be substituted for it. Jacobi has recommended such a 
mixture as this for a substitute: five ounces of barley-water, 
one or two drams of brandy or whisky, the white of an egg, and 
a little salt and cane-sugar; a teaspoonful to be given every 
hour. It is quite palatable. 

During convalescence or between attacks great care should be 
exercised to prevent overloading the stomach. It is best to 
vary food gradually and with watchful care. 

APPENDICITIS 

At the outset vomiting often occurs and makes the adminis- 
tration of food difficult. It is, however, best to abstain from 



298 APPENDICITIS. 

all foods, until pain and tenderness have gone, even if necessary 
for several days because nothing helps more to bring about im- 
provement than such abstinence from food. Water usually can 
be permitted in small quantities. Abstinence from food is most 
important as it helps many cases to recovery and puts others 
in the best condition possible for an operation. When food is 
given, it must be liquid and of such character as to be absorbed 
from the stomach as completely as possible. Much residue 
of food in the intestine will irritate it and provoke peristalsis 
that may be both painful and dangerous. Peristalsis may pre- 
vent adhesions and spread inflammation of the peritoneum. 
Broths, beaten eggs, peptonized milk, whey, and thin strained 
gruels are the best. 

After an operation food ought to be withheld for from 
twenty-four to thirty-six hours. Sterilized water may be given 
before and after operation. During recovery the amount of food 
should gradually be increased and changed in character, but 
for some time those articles that leave in the intestine con- 
siderable residue should be avoided. Especially coarse breads, 
coarse cereals, tough, fibrous meats, skins of vegetables and of 
fruits belong to this class. 

INTESTINAL OBSTRUCTION 

This disease does not admit of dietetic treatment. No food 
should be taken by the mouth. The severe vomiting that so 
often exhausts the patient is most likely to be relieved if the 
stomach is washed clean. Lavage may have to be practised 
several times daily. The colon also should be flushed fre- 
quently. As large an amount of hot water as possible should 
be introduced slowly into the intestine. By these means per- 
manent relief is afforded and the symptoms of collapse are 
avoided in many cases of acute obstruction. 

Thirst can be quenched by rinsing the mouth with water, by 
rectal injections, or by hypodermic injections of normal salt 
solution. If the symptoms of obstruction are not relieved 
promptly, rectal alimentation must be resorted to. When 
relief comes, only liquid food should be given by the mouth and 
in spoonful doses. The amount of food should be increased 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 299 

very gradually and afterward a change from liquid to solid 
food made slowly. 

Chronic obstructions must be removed or obviated by sur- 
gical operations. Prior to operation the treatment is the same 
as for acute obstruction except that in many cases a progressive 
stenosis precedes obstruction. During the peroid of stenosis 
foods that leave little residue may be eaten. As stenosis 
increases smaller amounts may be taken at longer intervals, 
and greater care must be exercised to keep the colon washed 
clean. As less food is eaten, rectal alimentation must be 
relied upon more and more. 

CONSTIPATION 

Causes 

Constipation, like diarrhea, may either be a symptom of 
disease or in many cases constitute of itself the complete morbid 
condition. Infrequent and small bowel movements are the 
phenomena of constipation. Mechanical obstruction within 
the bowel, or compression from without are sometimes causes 
of it. They constitute varieties of constipation requiring special 
treatment. Dietetic treatment may be of use in the beginning 
of these cases. Constipation is also caused by dietetic faults. 
Food may be insufficient in quantity or too concentrated; too 
little fluid may be drunk, or foods or drinks may be taken that 
are astringent and indigestible. It is rare that too much food 
taken at one time is the cause of obstructive constipation. 
More frequently it is due to a diminution of intestinal secretions 
and weakness of the intestinal muscles. Paresis of the bowels 
from spinal or cerebral disease sometimes prevents normal and 
regular defecation. In certain cases constipation is caused or 
aggravated by spastic contraction of the lower part of the colon. 
Worry and depression are frequent causes of this condition. 
In other cases that portion of the intestine is so sensitive as to 
be stimulated to contract by its usual contents. Many of 
these causes of constipation are removable. 

Chronic constipation leads to numerous complications. 
Among the commonest are sacral neuralgia and hemorrhoids. 
When feces become impacted or persistently lodged at one 



300 CONSTIPATION. 

point, they often excite local inflammation and temporary- 
diarrhea. In such cases from two to four days of constipation 
alternate with one or two of diarrhea. When impaction of 
feces lasts long, local pain and tenderness and sometimes fever 
will occur. Mental irritability, inability to concentrate the 
mind and to think clearly, lack of energy and ambition, are 
symptoms commonly associated with constipation. Headache 
and left-sided pleurodynia are also frequent accompaniments 
of it. 

Treatment 

In the treatment of this condition it is especially necessary to 
inquire carefully as to the habits of the patient, both in order to 
learn of possible causative conditions and to ascertain dietetic 
idiosyncrasies, if he has any. 

Nothing helps more to prevent constipation than regular 
habits of eating and of attempting defecation. The bowels 
should be moved each morning at a regular time. A habit 
may be thus acquired that is invaluable for the preservation of 
health. Mental worry and harassment should be avoided, for 
depressing mental states check peristalsis. A sedentary life 
is the commonest cause of constipation. It induces shallow 
respiration, lessened difference in intrathoracic pressure, and, 
therefore, less aspiration of lymph and venous blood into the 
thorax, which results in an imperfect removal of waste-products 
from the tissues of the abdominal organs. Lack of exercise also 
weakens the intestinal and abdominal muscles, and by pre- 
venting thirst, lessens the amount of water drunk and, conse- 
quently, diminishes intestinal secretions. It is not to be 
wondered at that those who lead a sedentary life are especially 
liable to constipation. To correct this condition enough 
exercise, preferably active exercise, must be taken to restore 
tone to voluntary muscles, to provoke deep breathing, and to 
force the use of the abdominal and other body muscles. Stoop- 
ing, bending, flexing the thighs against the body, and slow, deep 
breathing are especially useful exercises. Massage may be used 
as a substitute for active exercise and is often at first preferable to 
it in stubborn cases. Massage, while general, should be applied 
especially to the abdomen. Hydrotherapy is useful. Cold, wet 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 301 

packs and a cold spray upon the abdomen are the best forms of 
its application. Both massage and cold packs are more harm- 
ful than useful when spastic contraction of the colon causes con- 
stipation. Often in such cases hot applications to the 
abdomen and hot enemeta do good. 

Enemeta of olive oil given each night for two or three weeks 
and then for the same period every second night and for a third 
period at gradually longer intervals is very efficient in over- 
coming chronic constipation. From four to six ounces or 
from one-half to a whole cupful of oil is given at a time. It 
should be about body temperature and introduced into the 
bowel slowly and as high up as possible. It should be re- 
tained all night. Some of the oil is absorbed but much of it 
comes away with the stool in the morning. Its laxative effect 
is doubtless a local one and not due to its absorption. 

Occasionally individuals are met who have idiosyncrasies 
that cause or relieve constipation. As a rule, mental depression 
will provoke constipation, while mental excitement, particularly 
if the element of fear enters into the case, will sometimes 
produce diarrhea. Milk oftener produces constipation than 
diarrhea, but there are those who are physicked by it. Certain 
vegetables and fruits always have a pronounced laxative in- 
fluence upon some individuals, and more or less upon most 
persons. When they exist, these dietetic peculiarities are 
important guides to treatment. 

Diet 

In order to produce peristalsis it is essential that the in- 
testines contain a certain bulk of fecal matter. A diet rich in 
meat and eggs, and the sparing use of vegetables, fruits, and 
water will produce a small residue of undigested matter. 
Therefore the intestines will fill very slowly to a point sufficient 
to provoke vigorous peristalsis. When such a diet is habitual 
to a patient, it should be changed. Vegetables, fruits, coarse 
breads, and water should be taken freely. These foods should 
contain a large amount of cellulose, which remains undigested, 
fills the intestine, and excites in it peristaltic activity. 

The vegetables that are most laxative are tomatoes, spinach, 
lettuce, asparagus, Spanish onions, salsify, cabbage, and celery. 



302 CONSTIPATION. 

Spinach and tomatoes are especially prized for their effect upon 
the bowels. The coarse cereals have the same reputation. 
Oatmeal, cornmeal, and wheaten grits are the best. Bread 
made of coarse flour, such as Graham, rye, corn, oats, and 
'whole wheat' meal, also helps to prevent and to relieve con- 
stipation. Bran bread is especially efficacious. It is made by 
adding bran to ordinary flour or to graham flour in as large a 
proportion as is compatible with the making of good bread. 
Such breads as ginger-bread and Boston brown bread are also 
laxative, but often cannot be used because they provoke gastric 
indigestion. Agar-agar, a native of Japan, also produces the 
bulky stools which are needed. It is best given as a powder or 
mixed with a breakfast food. Two to four teaspoonfuls are 
given commonly each day and much more than this can be 
taken if it is needed. It is not digested or absorbed to an 
appreciable extent but helps to make a large stool, because 
it swells in the liquid contents of the intestine. It is the 
essential ingredient of several proprietary laxatives. 

Honey, molasses, and food eaten with them are also reputed 
useful for the relief of constipation. One patient of mine who 
had been afflicted with chronic constipation for years was able to 
keep his bowels in good order for months at a time by eating a 
home-made candy made of lard and molasses. Honey has 
been used in all ages as a mild laxative. 

Many persons are sensible of the stimulation of peristalsis 
that coffee produces. The addition to it of much sugar and 
cream will sometimes retard gastric digestion and may thus 
counteract its stimulating effect upon the bowel. 

Fruits have a laxative influence, partly because of the sugar 
that they contain, partly because of the fruit acids, and some- 
times because of their irritating skins and seeds. Berries — 
strawberries, blackberries, raspberries, blueberries, gooseberries, 
— currants, and grapes are effective partly because of their seeds 
and partly because of the acids that they contain or that are 
generated during digestion. Apples, pears, peaches, plums, 
cherries, oranges, and grape-fruit are chiefly purgative be- 
cause of their sugar and fruit acids. Prunes, figs, raisins, and 
dates have, besides these, either a skin, or seeds that act as 
local irritants in the intestines. 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 303 

Fruit produces the greatest laxative effect when eaten alone. 
It is, therefore, best taken at bedtime and on rising, a half-hour 
or, better, an hour before breakfast. A compote with meals 
will do good, although it is not so effective as fruit taken upon an 
empty stomach. Apple-butter, date-butter, marmalades, and 
similar preparations are often eaten upon bread or crackers. 
A mild but serviceable fruit laxative can be made by cooking 
together equal weights of dried dates, prunes and apricots 
until they are reduced to pulp. The skins must be removed 
by passing the mixture through a coarse sieve. It can be eaten 
freely alone or spread upon bread. It is agreeable and par- 
ticularly useful for constipated children. 

Many who are constipated fail to drink enough fluids either to 
keep the contents of the intestines soft or to form intestinal 
secretions as abundantly as is needful. This is especially true 
of those who lead a sedentary life, and of women. If, upon 
inquiry, it is found that enough water is not habitually taken, 
more must be prescribed. Slight constipation may often be re- 
lieved by a glass of cold water the first thing in the morning. 
The laxative effect is enhanced if another is taken at bedtime. 
The morning draft stimulates peristalsis and secretion. Under 
its influence the rectum is slowly filled, and a half-hour or an 
hour later, breakfast provokes the desire to defecate. The 
habitual use of hard water is constipating unless magnesium and 
sodium sulphates occur with the lime-salts in sufficient quanti- 
ties to make it laxative. Distilled water or soft water has a 
neutral action. Water containing much organic matter fre- 
quently provokes diarrhea. An average-sized man should 
drink from five to eight glasses daily. 

Sweet cider is loosening to the bowels. Grape-juice, if taken 
freely, acts similarly. Tea is an astringent, especially when 
made by boiling or prolonged leaching of the leaves. Tea 
drinking is not an uncommon cause of constipation. 

Only the mild cases of constipation can be relieved by dietetic 
and hygienic measures alone; but proper habits of eating, 
drinking, and living are essential to a perfect cure in any case. 
This is not the place to consider the value of electricity, mas- 
sage, and the various laxative drugs, but their help is often 
necessary. 



304 CATARRHAL JAUNDICE. 

Nurslings are at times constipated. The proportion of fats 
and proteins in their mothers' milk is frequently abnormal. 
This may be changed by suitable treatment of the mother. 
(See Part 1, Chapter xi.) Indigestion and constipation many 
times coexist in mother and babe. When the mother is re- 
lieved, the child often recovers. 

Frequently infants can be helped by giving them water to 
drink. When stools are hard and dry, water is needed. In 
other cases a few drops or a whole teaspoonful of olive oil, 
cod-liver oil, syrup, or malt or a little butter will relieve 
constipation. 

Oatmeal water is used as a laxative for infants. Condensed 
milk and 'prepared' foods are usually laxative. Massage, ene- 
mata of water, or water with a little salt, soap, or glycerin, or 
a glycerin or soap suppository must be employed in the most 
intractable cases. Sometimes calomel, castor oil, and other 
drugs must also be used. 

Children who are more than two and one-half years old and 
no longer upon an exclusive milk diet must be treated upon the 
same principles as adults. 

CATARRHAL JAUNDICE 

Gastritis and duodenitis, as a rule, coexist with catarrh of the 
bile-ducts. The diet must be adapted to this condition. 
Vomiting frequently prevents the administration of much food. 
In the beginning of such attacks the best article of food is milk. 
It should be given in small quantities and often. In some cases 
it may need to be peptonized or diluted with lime-water. As 
the symptoms of acute disturbance of the stomach subside, 
buttermilk, whey, broths of beef, chicken, mutton, clams, 
meat-juice, or raw egg may be employed as a partial substitute 
for the milk. 

te When vomiting, epigastric tenderness, and pain have disap- 
peared, one may add to these foods milk-toast, bread and milk, 
soft-boiled rice and milk, arrow-root, sweet-breads, oysters, 
meat-jellies, creamed codfish, boiled fish, squab, breast of chicken, 
scraped meat, and soft-cooked eggs. But they must be given 
at first in small portions and at long intervals. 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 305 

Fats, starches, and sugars should be avoided or used very 
moderately. When convalescence is established and jaundice 
has nearly or quite disappeared, breads, the simplest vegetables, 
and fruits may be eaten. The dietetic treatment is practically 
that of acute gastro-enteritis. 

OBSTRUCTIVE JAUNDICE AND GRAVE JAUNDICE 

When the common bile-duct is permanently obstructed or 
jaundice becomes persistent and deep, cerebral symptoms, such 
as mental irritability and depression, and later coma, delirium, 
or convulsions, and a slow pulse and subcutaneous hemorrhages 
develop. These are symptoms, at least in part, of poisoning 
caused by fermentation and putrefaction of the contents of the 
intestines, and by the failure of the liver to eliminate the toxins 
or to prevent their gaining access to the central nervous system. 

As soon as it is demonstrated that the cause of a jaundice 
cannot be removed, food should be prescribed in small amounts 
and of a character that will neither make great bulk in the 
intestines nor be liable to rapid putrefaction, so as to avert 
such poisoning and prolong life. Nothing meets these conditions 
so well as milk. Just as in uremia, an exclusive milk diet is best. 

The skin should be kept clean and active by frequent hot 
baths and by rubbing. An abundance of fresh air should be 
furnished the patient. 

Water should be drunk freely, so that elimination by the 
kidneys may be stimulated. Some of the toxins that will of 
necessity find their way through the liver into the general 
circulation may be eliminated by the skin and the kidneys. 
If the kidneys cannot be kept active by the milk and water 
taken by the mouth, therapeutic salt solution must be given 
by the rectum or hypodermically. Dietetic treatment, as well 
as medicinal treatment, is in these cases protective rather than 
curative. 

CHOLELITHIASIS, OR GALL-STONES 

Causes 

Gall-stones are composed chiefly of cholesterin, which is 
secreted by the mucous membrane of the gall-bladder and bile- 



306 GALL-STONES. 

ducts. Normally it is kept in solution by the bile salts of 
sodium and potassium (the taurocholate and glycocholate) . 
Cholesterin is formed in excessive amounts especially when 
there is catarrhal inflammation of the bile-ducts. The bile 
salts may be formed in relatively small amounts when the liver 
is inactive and when sufficient nitrogenous food is not eaten. 
Obstructions to the flow of bile, even when temporary or 
partial, predispose to the formation of stones. Sometimes 
foreign bodies form the nucleus of the concretions. Bile 
pigments and lime are occasionally ingredients of them. 
Sedentary habits also predispose to their formation. The 
claim that has been made that infection of the bile-ducts is 
essential to the formation of calculi is probably correct. 

It is rare that the gall-bladder or ducts contain only one 
calculus. As a rule, the stones are numerous and of a small or 
moderate size. Therefore, when their existence has been 
demonstrated by the occurrence of hepatic colic and jaundice 
or the discovery of them in the stools, it may be concluded 
almost with certainty that there are in the gall-bladder many 
others that will cause trouble in the future. There is no regimen 
that will cause their solution, but it is possible to prevent their 
growth and multiplication. 

Treatment 

It is extremely important that water be drunk freely to make 
the bile copious and thin. It has been thought that the pro- 
longed use of hard water increased the liability to the formation 
of gall-stones containing lime, but there is no adequate proof 
of this. Saline alkaline spring- water, such as that of Carlsbad, 
is particularly beneficial. Many patients have been observed, 
while under treatment at Carlsbad, to pass stones with com- 
paratively little discomfort. Carlsbad water and Carlsbad 
salts are extensively used in all parts of the world for the 
treatment of this affection. Wiesbaden, Ems, Vichy, Neuenahr, 
Marienbad, Kissingen, and Homburg are the chief European 
springs that are believed to be helpful. Saratoga, West Baden, 
and similar American spring- waters are also of value. Carlsbad 
salts are best given in hot water before breakfast. Before each 
of the other meals, one or two glasses of hot water should be 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 307 

drunk. It is generally believed that alcoholic beverages should 
be avoided or used very sparingly. Tea and coffee must be em- 
ployed only in small amounts; if there is much indigestion they 
should be forbidden. 

An abstemious diet is of more importance than a diet limited 
in character. The use of foods that prove indigestible must be 
stopped. The free or excessive use of starch and sugar must be 
forbidden, for instance, breads, cereals, potatoes, and foods to 
which much sugar is added. Nitrogenous or flesh food must 
be used in order to furnish the bile acid needed to hold choles- 
terin in solution. In this connection the observation of 
Thudicum is interesting, that in wild carnivora gall-stones are 
never observed, but that they are common in the domesticated 
herbivora and may occasionally be seen in pampered dogs fed 
on farinaceous foods. The simply prepared and easily digested 
vegetables, breads, and fruits may be used in moderate amounts, 
but the liberal consumption of starch, sugar, fats, fried foods, 
pastries, and other rich foods is very harmful. Even bread 
must be eaten moderately. The small pea, contains a choles- 
terin-like body, therefore, its use is generally inadvisable. 

Large doses of olive oil have been recommended for the re- 
moval of gall-stones. Clinicians are much divided as to its 
utility. Rosenberg has shown that it acts as an efficient 
cholagogue, producing a copious, thin bile. Gall-stones placed 
in olive oil lose weight and finally break up into small particles. 
However, the oil as oil cannot get to the stones in the gall- 
bladder or cystic duct. Possibly when a stone is impacted 
near the lower end of the common duct and all flow of bile into 
the intestine is stopped, the oil may find its way from the 
duodenum into the duct as far as the obstruction. In several 
instances when a calculus was thus impacted large doses of olive 
oil have seemed to me to do good. 

Dietetic treatment is, of course, unavailing for the relief of 
colic. Its object is to prevent the occurrence of colic. Ex- 
ercise, especially such as insures deep breathing and the use 
of the abdominal and body muscles, is necessary for the pre- 
vention of the formation of gall-stones. Women, who are 
paticularly prone to develop biliary concretions, should not 
lace tightly or in any way restrict their breathing. 



308 HEPATIC CIRRHOSIS. 

CIRRHOSIS OF THE LIVER 

This malady is generally believed to be incurable, but phy- 
siologic recoveries do occur. 

The common cause of hepatic cirrhosis is the habitual 
and excessive use of alcoholic beverages. It is occasionally 
due to syphilis or malaria, and rarely to other infections, 
such as tuberculosis and scarlet fever. That it may result 
from prolonged indigestion seems probable. Strong spices, 
curries, and similar condiments have also been blamed for 
its production. It is self-evident that the cause must be 
removed if possible. Alcoholic beverages should be forbidden 
in all cases. A change of climate may be needed for the malar- 
ious, and appropriate treatment for the syphilitic and the 
dyspeptic, cases. 

It has been shown repeatedly that a milk diet contributes 
more to recovery than any medicine or other factor of regimen. 
It is unfortunate that milk should have to be a patient's ex- 
clusive diet for many months, for it is difficult to maintain such 
a diet. But the patient must be made to understand that it is 
his only hope. Milk may be given cold or hot, according to 
taste. I believe it is longer relished if it is sometimes taken 
warm and at other times cold. As much as three or four pints 
should be drunk daily. This is best accomplished by taking 
a glassful every two or three hours from seven in the morning 
to nine or ten at night. 

When milk is not well tolerated, or when its exclusive use has 
been continued a long time, it is well to alternate periods of its 
exclusive use with periods when substitutes are taken. This 
mode of treatment is not the best, but is often necessary. A 
diet of milk can be varied by the eating of fruit, especially 
oranges, grape-fruit and lemons, without materially changing 
its character or lessening its value and it becomes thereby 
much more tolerable for the patient. The exclusive milk diet is 
sufficient so long as a patient is quiet, but it is not enough if much 
exercise be taken, or work be attempted. A complete disgust 
for it arises at times, and a modification of the regimen must 
be made. Bouillons or soups with a milk basis, egg and milk, 
or custards, warm or iced, may be tried. If they are well 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 309 

digested and the urine does not show an increase of coloring- 
matter, indican, and ethereal sulphates, their use may be con- 
tinued for a time, and Zwieback or pulled bread and a small 
quantity of vegetables and fruit may also be eaten. Such a 
diet is very grateful to those who have been upon an exclusive 
milk diet, but care must be taken at this time to give water 
freely so that elimination by the kidneys may be augmented. 
Tea and coffee may also be permitted, but they should not be 
sweetened with sugar. Saccharin may be used in its stead. 

Those who tolerate milk well, may continue to take a glass at 
seven in the morning, at eleven, at three in the afternoon, and 
at seven in the evening. At nine in the morning a cup of 
coffee with Zwieback may be taken with a little fruit. At one 
in the afternoon a milk soup, an egg, and a simple vegetable are 
allowable, and at five in the afternoon a supper of milk soup, 
an egg, or sometimes fish or oysters, Zwieback, a vegetable, and 
fruit may be had. String-beans, peas, and mashed or baked 
potato may be permitted in small amounts. Lettuce, tomatoes, 
chicory, carrots, turnips, spinach, salsify, and artichokes are the 
best. Meats should be avoided as long as possible. When 
their use is commenced, fish, oysters, squab, and breast of 
chicken are to be preferred. 

Starches and sugars are especially to be avoided. Vegetables 
and fruits containing much of them, potatoes, beets, other root 
vegetables and preserved and dried fruits, are not to be eaten 
freely, and not at all unless the case is progressing favorably 
and there is no indigestion. Condiments, rich sauces, fats, 
fried food, pastry, and sweets must be forbidden. 

A quiet out-of-door life should be led. Wearisome exercise 
must be avoided, as must also mental cares and worries. The 
skin should be kept active by warm baths and by rubbings. 
The bowel movements should be kept regular and copious, and 
the urine abundant. When ascites demands it, puncture of the 
peritoneal cavity must be resorted to, if necessary, repeatedly. 
However, a milk diet, about six glasses daily, rest in bed, 
laxatives and usually cardiac tonics will cause ascites often to 
disappear. The quantity of milk then can be increased and 
fruits also can be eaten but care must be taken not to over- 
tax the heart and liver. Toward the close of life, and espc- 



3IO ASCITES. 

cially in hypertrophic cirrhosis, hygienic treatment must be 
the same as in obstructive and grave jaundice. 

ASCITES 

Ascites is best relieved by puncture, and, if necessary, by re- 
peated puncture of the abdomen. When the amount of fluid 
in the abdominal cavity is small, diuretics, diaphoretics, and 
cathartics may be used with some hopefulness. Dietetic 
measures are governed by the existing cirrhosis of the liver or 
by other causes of the dropsy. It is often a question whether 
a dry diet should be prescribed or the copious use of fluids 
permitted; sometimes this question can be answered only by 
trial. Cirrhosis and gastric and intestinal indigestion may 
counterindicate a dry or concentrated diet. If the ingestion of 
fluids be temporarily discontinued, enough fluid will sometimes 
be absorbed from the peritoneal cavity to augment the urine 
and reduce the ascites. When the kidneys do not eliminate 
all the fluid that is drunk, it is best to try the effect of a dry 
diet, provided fermentation and putrefaction in the stomach 
and intestines do not make it dangerous. In my experience, 
however, small quantities of milk only (five or six glasses 
daily), helped by laxatives and cardiac tonics, are surer to re- 
move ascites than a dry diet and it is much more agreeable to 
the patient. It is rare, however, that by medication or dietetic 
management ascites can be much relieved. The trocar and 
cannula are needed in almost every case. 

PERITONITIS 

Acute generalized peritonitis is so rapidly fatal that dietetic 
treatment cannot be said to form a part of its management. 
Vomiting usually prevents the taking of food by the mouth. 
If food is forced upon a patient, it produces peristalsis and pain 
and soon renewed vomiting. Small quantities of water or bits 
of ice may be given frequently when the symptoms are least 
urgent. One or two spoonfuls of predigested milk may be 
administered occasionally, so that from six to twelve ounces 
may be consumed during the day. Albumen-water or very thin 
gruels of barley or arrow-root may be substituted for predigested 



DISEASES OF THE INTESTINES, LIVER, AND PERITONEUM. 311 

milk, but under the circumstances they are not so suitable as 
the latter. The accumulation of an undigested residue in 
the bowel should be avoided. 

Strength must be maintained mainly by nutritive enemata. 
Intestinal flatus may be removed partly by purgative enemata 
of water and by the passage of a long rectal tube. Farinaceous 
foods are apt to increase meteorism, wherefore their use is not 
advisable. Turpentine stupes and turpentine in enemata 
afford some relief of this symptom. 

The malady is so uniformly fatal that treatment is of little 
avail. It must be aimed to palliate suffering and to preserve 
strength. Stimulants are often given in these cases. Dry 
champagne will sometimes be retained by an irritable stomach 
when other substances are vomited. It should be taken in sips. 
Dilute brandy and whiskey are also used, especially when symp- 
toms of collapse appear. 

Localized acute peritonitis from any cause whatsoever, must 
be treated, so far as diet is concerned, as has already been ad- 
vised for appendicitis. 

Chronic peritonitis requires the use of foods that will leave 
little residue in the intestines and that are least likely to ferment 
there. The fermentation of starches and sugars is especially 
likely to distend the bowel with flatus, thereby causing increased 
discomfort. The intestines should be kept clean. Enemata 
may be needed. Sometimes mild purgatives may also be 
required. 

Water should be given freely, both to promote the formation 
of intestinal secretions and thus to make soft stools, and to pro- 
mote free elimination by the kidneys. 

Simply prepared animal foods are the best. Milk, tender 
lean meats, finely divided and completely chewed, fish, oysters, 
and eggs must be the staples. Stale breads may be used 
sparingly; Zwieback, pulled bread, and toast are the best. The 
simplest vegetables and purees may be eaten. Cereals, soft- 
boiled rice, tapioca, and similar foods may be used providing 
fermentation does not counterindicate them. 

Food should be eaten in very moderate amounts at a time, 
and every precaution should be taken to prevent intestinal 
indigestion. 



CHAPTER VI 

DISEASES OF THE RESPIRATORY ORGANS 

Laryngitis. Laryngismus Stridulus . Bronchitis. Emphysema. 
Asthma. Croupous Pneumonia. Pleurisy and Empyema. 

LARYNGITIS 

Mild laryngitis, acute or chronic, requires no modification of 
diet. Appetite is often lessened, and food is voluntarily re- 
stricted to the simplest kinds. 

Ulcerative laryngitis, such as occurs in tuberculous and 
syphilitic affections, causes much difficulty in swallowing. So 
painful is deglutition, that starvation may be preferred to the 
attempt to swallow, unless the pain can be relieved by local 
analgesics. Under these circumstances life must be maintained 
by rectal alimentation. So long as food can be swallowed, 
however, it should be taken by the mouth. An excellent anal- 
gesic application is a 10 or 15 per cent, emulsion of orthoform in 
almond oil, made with the aid of yolk of eggs. It should be given 
about ten minutes before feeding, to be held in the mouth and 
slowly swallowed, or, better, may be slowly injected in and 
around the larynx by means of a curved syringe under laryn- 
goscopy guidance, and after preliminary cleansing of the parts 
by an alkaline sedative spray. Lozenges of orthoform in some 
soft vehicle may be used instead. Liquids and the softest foods 
are the most easily taken. The diet must finally consist ex- 
clusively of milk, gruels, broths, purees, eggs, soft custard, 
ice-cream, and weak tea and coffee. Of solids or semisolids that 
may be eaten during the earlier part of the illness, jellies, milk- 
toast, bread and milk, scraped beef, oysters, and similar dishes 
are the best. Sometimes, even to the last, semisolids such as 
custards and jellies, or a raw egg bolted whole, can be taken 
with less pain than is caused by liquids. 

312 



DISEASES OF THE RESPIRATORY ORGANS. 313 

Some patients find it possible to swallow with least discom- 
fort if they lean forward or even lie face downward, with the 
head hanging over the edge of the bed. In this position liquids 
can be sucked into the mouth through a glass tube and the in- 
flamed and irritated larynx is least likely to be touched by food 
or moved in the act of deglutition. Feeding through an esopha- 
geal tube introduced either through the nose or the mouth is 
sometimes the best method. In such cases the preliminary use 
of a local analgesic, such as cocain, holocain, eucain, etc., is 
often necessary. 

LARYNGISMUS STRIDULUS 

Dieting is chiefly of use as a prophylactic measure in those 
cases in which indigestion is the exciting cause. By feeding an 
infant or child carefully, flatulence, indigestion, and constipa- 
tion may be prevented. These conditions are often the 
immediate cause of attacks of laryngismus stridulus. 

Rickets, or a tendency to rickets, increases the liability of a 
child to croup. If it is old enough, meat -juices, broths, eggs, 
and fruit -juices should be eaten, although milk should still con- 
stitute the chief article of diet. Cod-liver oil and the phosphates 
are important adjuvants. Hard-fried bacon is good in this 
class of cases, and may be eaten freely by children fifteen 
months or more old. 

BRONCHITIS 

In those cases of simple acute bronchitis that are accompanied 
by fever, diet must be the same as for mild infectious diseases. 
Liquid food for the most part, or soft foods if relished, such as 
custards, milk-toast, cereals, blanc mange, and corn-starch, are 
the best. When there is no fever, it is sufficient to restrict the 
patient to small portions of simply prepared foods. In this, as 
in so many other acute inflammations, a feeling of well-being is 
much enhanced by prompt, free purgation. 

In the early stage of acute colds, when coughing is severe and 
unsatisfactory because the secretions are too tenacious to be dis- 
lodged from the bronchial tubes, they can be made thinner and 



314 BRONCHITIS. 

their expulsion easier by drinking freely of fluids. Hot fluids 
especially are soothing and lessen the frequency of the coughing. 
A hot lemonade, weak tea, hot milk, a punch, and hot bouillon 
are serviceable under these circumstances. In simple bron- 
chitis, when only the large bronchial tubes are affected, this 
dry stage is of short duration. As soon as the cough becomes 
loose, fever, if present, disappears, and with it most of the 
discomfort of the cold. Then a normal diet may quickly be 
resumed. 

Capillary bronchitis and catarrhal pneumonia must be con- 
sidered as they occur in three groups of patients — infants, the 
aged, and the middle-aged. They are least severe in the last. 
In the earliest and lastest years of life the necessity of sustaining 
strength is especially great. The constant labor of breathing 
and the frequent wearying attacks of coughing tend to exhaust 
those who have not much vitality. Fever is also commonly 
present, and ranges high when pneumonia complicates the 
bronchitis. This is an additional factor tending to bring on 
exhaustion. Appetite is wanting. Eating makes breathing 
more difficult and often provokes coughing; therefore food is 
frequently spurned. Under these circumstances it becomes a 
problem to maintain strength. Milk must constitute the 
chief, if not the only, food for small children during the first 
few days of the illness. It should be given in small amounts and 
often. If it is not relished, it should be given in spoonful doses 
every half-hour or hour. Older children may be given broths 
and gruels alternately with milk. Hot drinks are most grateful 
to them and least likely to provoke coughing. In extreme 
cases it may be necessary to resort to nutritive enemata to help 
maintain strength. 

The patients should be kept in rooms in which the temperature 
is uniform and about 75 F. It is often beneficial to keep the 
air of the sick-room moist, as the secretions are made thinner 
thereby and consequently are more easily dislodged. Hot 
baths and hot poultices give great relief to infants and little 
children. For the aged, light poultices are comfortable, pro- 
vided they are well made and kept hot. 

As soon as convalescence is established, patients may be fed 
more generously. The transition from a liquid diet to a nor- 



DISEASES OF THE RESPIRATORY ORGANS. 315 

mal one should be made somewhat gradually, just as in measles 
or other acute febrile disease. 

Capillary bronchitis in middle life is especially likely to occur 
in obese individuals and in those who have lithemic tendencies. 
For the former, a reduction of flesh is an important prophylactic 
measure, while the promotion of free elimination by the kidneys, 
skin, and lungs, together with a diet that will prevent excessive 
nitrogenous waste, and exercise that will promote vigorous 
normal tissue changes, are equally valuable for the latter. An- 
tirheumatic treatment is often of the greatest use because it 
relieves attacks when they occur. Water and milk should be 
taken freely; solid foods, sparingly. For the time being, red 
meats should be forbidden. Even eggs, fish, and breast of 
fowl should not be eaten generously. The liquid diet will both 
promote elimination and make the secretions in the bronchial 
tubes more fluid and easier to dislodge. 

The bowel should be emptied thoroughly each day. If, as is 
often the case, chronic indigestion exists, it should be palliated 
or relieved. Flatulence and gastric or intestinal distention 
cause respiratory oppression that greatly increases the patient's 
discomfort. They also increase arterial blood pressure and give 
more work to a heart often sorely taxed already by bronchial 
congestion. The danger of cardiac exhaustion and edema of the 
lungs, complications that are imminent in those who are weak, 
is thus increased. 

In chronic bronchitis, when an acute exacerbation occurs, the 
dietetic and hygienic treatment is the same as in acute bronchitis. 
In mild cases of chronic winter cough a normal regimen should be 
followed. When, in individual cases, the bronchial secretions 
are tenacious and thick, an abundance of fluid should be taken. 
Hot drinks are especially good. Many patients think that 
lemon-juice added to their beverages 'cuts the phlegm, ' and 
are both pleased and comforted by it. 

In other groups of cases the secretions are excessive. A dry 
diet is then of equal value. It is especially indicated in bron- 
chorrhea. But a residence in a dry air is of greater value than a 
dry diet. Although the quantity of secretions from inflamed 
mucous membranes may be modified greatly by partaking 
freely of fluids or abstaining from them, the character of the 



316 ASTHMA. 

secretion cannot be changed. A mucous, mucopurulent, or 
purulent exudate will remain unchanged in character by diet. 
The constant inhalation of clean air will, however, often modify 
its character. Nothing contributes more to aggravate chronic 
bronchitis than breathing air made impure by being repeatedly 
breathed, which is the case in badly ventilated rooms or by 
breathing dust-laden air. Natural atmospheric changes are a 
provoking cause of acute exacerbations of chronic bronchitis less 
frequently than violent changes of temperature and moisture 
produced artifically by overheating rooms and by baking the 
air in them. The change necessarily felt in going from such 
rooms to a cold, damp air out-of-doors is much greater than 
that which nature produces. Climatic prescriptions are, 
therefore, of much greater value in most cases of chronic 
bronchitis than are dietetic ones. 

EMPHYSEMA 

The discomfort of emphysema is much aggravated by gastric 
and intestinal disorders. These should, therefore, be prevented 
or corrected. The patient should eat sparingly of simple food. 
In the most chronic cases, when the heart has become feeble and 
digestion most impaired, the diet must be mainly, and some- 
times exclusively, a liquid one, with milk for its basis. 

ASTHMA 

Indigestion and constipation are observed by asthmatics to 
be predisposing causes of many attacks. They provoke at- 
tacks of asthma as the same conditions aggravate capillary 
bronchitis. There is no doubt that in some cases the toxins 
absorbed from the intestinal tract play a part in producing the 
disease. 

Asthmatics very frequently exhibit idiosyncrasies. As 
certain perfumes cause attacks in some persons, so will certain 
foods in others. When diet plays any part in bringing on disease, 
the case must be studied with care as to the influence of each 
article of food; for instance, pork may provoke attacks in one 
person and lobsters or other sea-food in another. Strong coffee, 



DISEASES OF THE RESPIRATORY ORGANS. 317 

on the other hand, will sometimes shorten attacks. Many 
patients must avoid starches and sugars, or use them with 
great moderation. In many cases peculiarities of diet play 
no part in the causation of asthma, and for such, a dietetic 
prescription is unnecessary. It is alway well, however, when 
attacks occur during the night or early morning, to forbid a 
heavy evening meal, and especially to warn the patient against 
taking any food whatever late at night. 

CROUPOUS PNEUMONIA 

This disease must be treated dietetically, as are the other acute 
infectious fevers. In pneumonia, appetite is diminished and 
thirst is increased; frequently delirium makes a patient ob- 
livious to hunger and thirst ; when this is the case, the sufferer 
should be fed regularly. Liquid food is the easiest and best to 
administer. When milk is well tolerated, it should be employed 
as the staple article of food, but care should be taken not to 
overload the stomach, for if it is distended, it will impede 
respiration and circulation. The bowels should also be well 
emptied at the onset of the illness and moved daily thereafter. 
It is not necessary that the diet consists of milk only. Broths, 
eggs and milk, thin custards, and gruels may also be eaten. In 
severe cases a modicum of nourishment should be given every 
two hours; in milder ones, somewhat more may be given at 
longer intervals. In the mildest cases soft-cooked eggs, corn- 
starch pudding, gelatin jellies, milk-toast, and soft-boiled rice 
may be eaten in small amounts, in order to vary the monotony 
of the milk diet. 

In severe cases, especially in advanced life, it is of great impor- 
tance to maintain strength. Sufficient nourishment can usually 
be given by the mouth, but occasionally it may be necessary to 
resort to nutritive enemata. 

While breathing is rapid and labored, swallowing is more or 
less of an effort, because it quickens respiration, which is there- 
fore made more difficult. Under these circumstances only a 
few swallows of liquid food can be taken at one time. 
When delirious, patients frequently refuse food. Fortunately, 
pneumonia is usually of short duration, and abstinence from 



318 PNEUMONIA. 

food for a few days is not of serious import, except when the 
illness attacks those who are feeble or is prolonged by a spread 
of the pulmonary inflammation. Those cases in which fever 
does not disappear by crisis on or before the fifth, seventh, or 
ninth day must be fed with care. 

A transient febrile albuminuria is of the commonest occur- 
rence in pneumonia, but it does not demand a special diet. 
When it does occur, the bowels should be emptied thoroughly 
and liquids, particularly water and milk, should be given 
freely. Occasionally true nephritis arises, and then a milk diet 
is essential. Pains should be taken to prevent abnormal 
fermentation in stomach or bowels and the retention of fecal 
matter. 

Alcoholic beverages have been given with the greatest freedom 
in this disease. An ounce of whisky or brandy an hour has 
been a not unusual dose. Alcohol is not, however, used so freely 
as in the past, since many more valuable remedies have been 
discovered. From what has already been written of its mode 
of action, it is evident that it is valueless as food and often 
of little use as a cardiac tonic. Conditions often exist that 
counterindicate its use. The employment of nitroglycerin, 
strychnin, saline infusions, and oxygen gas has greatly lessened 
the use of alcohol. Cases of all grades of severity can be 
treated successfully without it. Patients who have been 
accustomed to drink alcohol freely are especially prone to 
develop delirium tremens during an attack of pneumonia. To 
them whisky is usually given in gradually diminished doses. 
Among such patients the mortality is especially great. 

After crisis the diet should not at once be changed from 
liquids to soft foods, as the best results are had if this change is 
not begun until the third day after, when convalescence is 
established and appetite and the ability to digest and assimilate 
food have returned. But once it is begun, a change from 
milk to soft food and then to solids can be made rapidly, ex- 
cept when the course of the illness has been long or the patient 
is unusually feeble ; then as much care in making the change is 
necessary, as after typhoid fever. Usually the most vigorous 
patients are able to eat solid food at the end of the first week 
after convalescence is established. In such cases care must be 



DISEASES OF THE RESPIRATORY ORGANS. 3 10, 

exercised that patients are not overfed, for too much food is 
more harmful than a variety of simply prepared solid food. 

Tea and coffee may be given during the whole course of the 
disease if they are craved. The last named is a useful adjuvant 
to cardiac tonics. 

Patients having croupous pneumonia should always be 
treated in large, well-ventilated rooms. The air should be 
kept uniformly at from 65 to 70 F. An abundance of fresh 
air is needed. 

PLEURISY AND EMPYEMA 

Fibrinous pleurisy demands no dietetic treatment unless 
effusion follows it. 

Pleurisy with effusion necessitates a nutritous diet to maintain 
strength, and one that will promote a reabsorption of the exudate 
if possible. Simple foods containing little fluid are the best. No 
beverages should be used except water, and that should be 
taken in as small quantities as possible. In this way the 
rapidity with which an effusion develops will be lessened or its 
amount will be limited, and if inflammation has subsided, a rapid 
absorption of the exudate will be promoted, as the system will 
satisfy its demands for fluid by drawing upon what is stored in 
the pleural cavity. 

Tender lean meat, breads, a mealy potato, spinach, lettuce, 
or string-beans constitute a list of suitable foods. The patient 
must be instructed to drink water as rarely as possible, and then 
only a swallow at a time. This mode of treatment is of un- 
doubted value. What is known as the Schroth method con- 
sists in feeding a patient upon lean roast veal, stale rolls, and a 
trifle of water for three days, when a half pint of red wine is 
added and gradually increased to one pint at the end of the 
week. 

A strict milk diet has also been advocated for these cases. 
One or two quarts are given daily in small hourly doses. There 
is no advantage in this unless derangement of the stomach or 
bowels prevents the use of the dry diet. 

In spite of dietetic treatment, thoracentesis must often be 
resorted to. After the mechanical withdrawal of the fluid a 



320 PLEURISY. 

dry diet should be maintained for several days, to prevent the 
reaccumulation of the exudate. To the many cases of tubercu- 
lous pleurisy, applies what has been said of the dietetic treat- 
ment of phthisis pulmonalis. 

Empyema must be treated dietetically as a pleurisy with 
effusion, but even greater care must be exercised to maintain 
strength. 



CHAPTER VII 

DIET IN DISEASES OF THE BLOOD 

Simple Anemia. Chlorosis. Pernicious Anemia. Leukemia. 
Pseudoleukemia . 

SIMPLE ANEMIA 

Simple anemia cannot be regarded as a pathologic entity; it 
is secondary to some other morbid condition. Although the 
primary ailment may not always be discoverable, it should be 
sought for in every instance. All maladies that are accom- 
panied by hemorrhage, whether it be considerable or small, or 
that cause destruction of blood-corpuscles within the blood- 
vessels, will produce anemia. We likewise find this condition 
occurring in connection with many constitutional affections 
in which nutrition is disturbed and there is a failure of function 
on the part of the blood-producing tissues. The cases of simple 
anemia in which it is most difficult to discover a cause are 
chiefly met with among those who are imperfectly nourished 
or for some reason are leading an unhygienic life. They are 
usually individuals who have gradually become enfeebled by 
their mode of life, or by a diet deficient in quantity or quality. 
In many instances anemia can be corrected without medicinal 
treatment, by the necessary changes in the life of the patient. 

As simple anemia is secondary to other maladies, necessarily 
the details of the treatment can best be described in connection 
with the primary affections, and need not be repeated here. It is 
always essential that the diet be so adapted to the needs of 
the individual that it will not produce indigestion and that it will 
afford an abundance of nourishment. The general principles 
are the same that apply in cases or chlorosis, and the dietetic 
and hygienic regime is fully described in the next section of 
this chapter. In a few instances simple anemia will be found 
to accompany hypochlorhydria, and the diet will then have 
to be adapted to the digestive powers of the stomach. It must 
21 321 



322 ANEMIA. 

be that which would be prescribed in a case of chronic gastritis 
in which gastric juice is deficient. An abundance of fresh air, 
active exercise within the capacity of the patient, and, if possible, 
a change of climate as well as of diet, are desirable in nearly 
all cases. 

It must be remembered that iron derived from food is 
needed to make hemoglobin but that inorganic as well as or- 
ganic compounds of iron will stimulate the production of blood 
corpuscles. Macallum and others have shown that iron of all 
kinds is taken into the lymph channels and first deposited in 
nodes and spleen and later distributed widely to the organs 
and tissues of the body. If iron is excluded from the diet of 
animals they do not thrive and when it is not supplied to those 
in whom anemia has been artificially produced a restoration to 
health does not take place. The experiments ot Hauserman 
demonstrate that inorganic iron will not prevent the develop- 
ment of anemia if only food poor in iron is given during long pe- 
riods of time. Nevertheless inorganic iron can stimulate blood 
formation although it does not seem to enter into the pro- 
duction of hemoglobin. 

Most of the iron which is administered to patients is un- 
absorbed from the intestines, moreover, iron is eliminated 
through the walls of the intestines as well as absorbed through 
them. It has been shown that a fasting animal eliminates 10 
milligrams in feces per square meter of surface of intestines; 
and only a trifle more when food poor in iron is given, but when 
food rich in iron is eaten from 43 to 78 milligrams per square 
meter of intestines is found in the feces and in an isolated 
intestinal loop only 6 or 8. Therefore the conclusion stated 
above can be drawn that small quantities are eliminated by 
the intestines, and that when large quantities are eaten most 
of it remains in the feces unabsorbed. 

These physiologic facts point to the need of dietetic man- 
agement in anemias. The following list of common foods and 
their content of iron will be useful in guiding one in the pre- 
scription of a diet. However, in simple anemia as has already 
been said, the condition of digestion and the nature of the 
disease producing the anemia must largely govern one in select- 
ing a diet. 



DIET IN DISEASES OF THE BLOOD. 323 

Per cent. 

Beans, lima 0072 

Beans, navy 0067 

Whole wheat 0052 

Spinach 0038 

Meat 003 75 

Oatmeal 003 7 

Raisins 0036 

Eggs 003 

Prunes 0029 

Beans, string 001 6 

Wheat flour 0015 

Corn meal 00 1 

Potatoes 0012 

Cabbage 0009 

Corn 0008 

Rice 0007 

Apples 0003 

Milk 00024 

Ten or twelve milligrams of iron in food will maintain equi- 
librium. This amount is easily supplied by the average diet 
of men. 

CHLOROSIS 

Chlorosis is recognizable by the greenish pallor which devel- 
ops in the face of those who are affected by it, and by the blood- 
less appearance of the ears, lips, and mucous membranes. 
Usually emaciation is not observable, although there is often 
some loss of flesh. Breathlessness on exertion and palpitation 
of the heart are complained of commonly. Patients generally 
lack both energy and endurance. Neuralgias are not uncom- 
mon. Digestion is almost invariably impaired. Indeed, de- 
rangement of digestion often precedes the anemia. Dilatation 
of the stomach exists in more than one-half of all cases. The 
secretory activity of the stomach varies, but in the largest 
number of cases there is increased secretion of hydrochloric 
acid. The proportion of cases of hyperpepsia to those of hypo- 
pepsia is approximately as 3 to 2. In a smaller number of 
cases the gastric juice is normal. Round ulcer of the stomach 
is a common complication. Constipation is the rule in this 
ailment. Menstruation is irregular, deficient, or wanting. In 



324 CHLOROSIS. 

severe cases a little edema is often observable about the eyelids 
and ankles. 

Blood examinations show that a moderate reduction of red 
blood-corpuscles occur, with a great reduction of hemoglobin. 
In cases of average severity, the red corpuscles will vary from 
three to four millions, but the hemoglobin will range from thirty 
to thirty-five per cent. 

Cause 

The essential cause of chlorosis is unknown. That it is some- 
thing which interferes with the production of hemoglobin or 
hastens its destruction seems evident. By many clinicians 
chlorosis is believed to be due to an intoxicant generated in the 
intestinal canal. However, positive proof of this is wanting. 
It is generally admitted that the disease frequently recurs in 
the same family, and an inherited tendency to it is thought to 
exist. A sedentary life, hard work, emotional disturbances, and 
deficiency and unsuitability of food are predisposing conditions. 
In most cases, gastro-intestinal derangements of more or less 
chronicity will be found to have preceded the onset of char- 
acteristic symptoms. 

Treatment 

Rest is an essential element of treatment. In some cases 
patients should be kept in bed for some days, or, if the climate 
will permit, recumbent in the open air. In mild cases long 
hours of rest and gentle, measured exercise must be prescribed. 
Rest prevents wasting of stength and tissues, while the blood 
is too deficient in power to carry oxygen to maintain good 
nutrition. Rest is also essential because the heart is weak 
and because the anemia produces breathlessness if more than 
a little exertion is made. When improvement has been 
effected, a little exercise may be permitted, and it may grad- 
ually be increased. A dry rub with a coarse towel is desirable 
in most cases both night and morning. Often the stimulating 
effect of this rub can be increased if it is preceded by a sponge 
bath of tepid or cool salt water. 

When active exercise is taken, it should not be enough to 
produce palpitation or shortness of breath or a degree of wear- 



DIET IN DISEASES OF THE BLOOD. 325 

iness which cannot be readily recovered from by a rest of a 
few minutes. 

A change of climate often does good, especially a sojourn at 
some quiet hamlet, at the seashore, or at a sheltered spa with 
chalybeate waters. When season and climate permit, the 
patient should be kept as much as possible out-of-doors. If 
treatment must be carried on indoors, the living and sleeping 
rooms should be large, perfectly ventilated, bright, and cheer- 
ful. Depressing and exciting conditions are so often harm- 
ful that treatment at home frequently becomes tedious and 
unsatisfactory. 

Dietetic management is most important, both in order to 
restore to the blood the iron in which it is deficient and to cor- 
rect the disturbed functional activity of the digestive organs. 
From the commonly disturbed state of digestion and enlarge- 
ment of the stomach it becomes necessary to give food which is 
easy to digest, which is not bulky, and which is nutritious and 
contains a good percentage of iron. When the stomach is 
much dilated, it should be cleansed; if necessary, by lavage. 
Abstinence from food except a minimum amount of milk, and 
water enough to flush the stomach, will prevent its distention 
and help to keep it clean. A dose of Carlsbad salts in a glass 
of water taken before breakfast is of value in all cases. So 
soon as stomach and bowel have been well emptied meat and 
eggs should be given freely, liquids sparingly, and fats and car- 
bohydrates not at all. The diet will then consist of chopped 
or scraped beef, mutton, chicken, squab, lean cold boiled 
ham, eggs, a little lettuce, raw tomatoes, or spinach, whole wheat 
bread, or Zwieback, raisins, prunes, oranges or apples. This 
strongly albuminous diet will agree especially well with those 
cases in which there is hyperchlorhydria. If the gastric juice is de- 
ficient, hydrochloric acid should be given with each meal, and food 
should be eaten often and in small amounts at a time. When 
the stomach has regained its normal dimensions and peristalsis is 
sufficiently active to prevent the accumulation of food in the 
stomach, the diet can be made more generous, and larger 
quantities can be given at longer intervals. 

Pastries and sweets are often eaten with especial relish by 
those who are chlorotic. Such foods, however, are actually 



326 CHLOROSIS. 

harmful in most instances, for they are indigestible. The 
appetite of those who are chlorotic is frequently capricious, and 
craves acids as well as sweets and many other useless or harmful 
articles. 

When the stomach is not enlarged and there is hyperchlor- 
hydria, an exclusive milk diet will give the greatest comfort. 
As soon, however, as digestion becomes comfortable, lean meat 
and eggs should be added to the diet. When the gastric juice 
becomes normal, the green vegetables and bread can be eaten 
in small amounts, and later, when convalescence is established, 
a greater variety may be introduced into the dietary. 

Although the iron needed to restore what the blood has lost 
can be obtained from food, it can be advantageously given as 
a medicine. It is doubtful if the latter restores to the blood the 
needed iron, and Bunge's suggestion that it unites with and 
makes inert the sulphids in the intestines, and therefore permits 
the better absorption of the organic iron of foods, has not been 
established. Unquestionably, however, ferruginous prepara- 
tions do good, in all probability by stimulating blood production. 
It is equally necessary to administer laxatives to most patients. 
Among the best are Carlsbad salts and spring-waters of 
similar composition. 

The following list of foods with their iron contents, prepared 
chiefly by Bunge, is of use in selecting a diet for the chlorotic, 
and will supplement the list given on page 323. 

Rice 100 grams contain 1 . 8 milligrams of iron 

Rye 100 grams contain 4 . 9 milligrams of iron 

Wheat 100 grams contain 5 . 3 milligrams of iron 

Oats 100 grams contain 13 . 1 milligrams of iron 

Corn 100 grams contain 3 . 6 milligrams of iron 

Potatos 100 grams contain 2 . o to 6.4 milligrams of iron 

Peas 100 grams contain 6 . 6 milligrams of iron 

Beans 100 grams contain 7 . 4 to 8.3 milligrams of iron 

Lentils . 100 grams contain 8 . 3 to 9.5 milligrams of iron 

Apples 100 grams contain 13.2 milligrams of iron 

Strawberries 100 grams contain 8. 9 milligrams of iron 

Cabbage 100 grams contain 3 . 9 milligrams of iron 

Spinach 100 grams contain 35-9 milligrams of iron 

Cow's milk 100 grams contain 2.3 milligrams of iron 

Human milk 100 grams contain 2 . 7 milligrams of iron 

Beef 100 grams contain 4.8 to 16.6 milligrams of iron 



DIET IN DISEASES OF THE BLOOD. 327 

Eggs 100 grams contain 5 . 7 milligrams of iron 

Fish 100 grams contain 1 . 5 to 84 . 2 milligrams of iron 

Veal 100 grams contain 2 . 7 milligrams of iron 

It is of great importance also, to select food that is easily 
digested and that is least likely to ferment or putrefy in the 
stomach or intestine. 

It is generally admitted that stimulating beverages, not only 
alcoholics, but tea and coffee, should not be used. In mild 
cases they may be permitted in small amounts. Their use is 
conditioned rather by the state of digestion and of the nervous 
system than by any effect which they have upon the blood. It 
must be remembered, however, that alcohol interferes with the 
oxygen-carrying power of the blood. It tends, therefore, to 
aggravate the essential pathologic feature of the disease. 

An error often committed in treatment is the discharge of a 
patient as cured as soon as color is restored to her lips and 
cheeks, menstruation reestablished, and discomfort during 
digestion relieved. In almost every instance in which this is 
done a relapse soon occurs. Although in most cases great 
improvement is rapidly effected, a permanent cure can rarely 
be accomplished in less than from three to six months. During 
this time care should be taken as regards mode of life and diet 
and especial pains taken to maintain regular and copious 
bowel movements. 

PROGRESSIVE PERNICIOUS ANEMIA 

Pernicious anemia is characterized by the presence of an un- 
usually small number of red blood-cells. In average cases they 
count approximately 1 ,000,000 to the cubic millimeter. Simply 
a great reduction in the red corpuscles is not enough, how- 
ever, to establish a diagnosis of the malady. A large number 
of megaloblasts is particularly pathognomonic. Usually as 
many as one-third or more of the red cells are of this large 
variety. The red corpuscles vary much in shape and are 
frequently unusually small as well as large. Nucleated cells are 
commonly seen. Many do not stain evenly, and in others the 
hemoglobin is not uniformly distributed. Evidences of de- 
generation are common. The white cells are reduced in number. 



328 PERNICIOUS ANEMIA. 

Hemoglobin, although less abundant than in normal blood, 
occurs in larger proportion than do the red corpuscles, or at least 
falls little below what would be expected because of the reduction 
in corpuscles. The amount of hemoglobin is usually high in pro- 
portion as megaloblasts are numerous. So great a degree of 
anemia is naturally accompanied with pallor, feebleness, pal- 
pitation on exertion, shortness of breath, and often dizziness 
or faintness. 

Digestion is frequently impaired. Nausea and vomiting 
occur from time to time in most cases. Constipation is the 
rule. The kidneys act normally, but the urine commonly con- 
tains an unusually large amount of indican and other ingredients 
indicative of putrefaction of the contents of the intestine. 
Sometimes the sternum and long bones are tender. Frequently 
the heart is dilated ; anemic murmurs are audible over it and 
the large vessels. Ocular and cerebral hemorrhages are 
occasional complications. Spinal degeneration irregularly dis- 
tributed causes paresthesia and sometimes exaggerated reflexes 
and unsteadiness in walking or inability to do so. The hands 
may be similarly effected though usually they are less fre- 
quently and less severely involved than the legs and feet. 
These spinal symptoms develop sooner or later in almost 
every case. 

Causes 

The pathogenesis of the disease is unknown. There are two 
groups of cases; one in which the anemia is secondary, and 
another in which it is apparently primary. As the syndrome 
does not develop in every case in which, so far as our knowledge 
goes, it might be expected to, it seems probable that a predis- 
position to the malady may exist. Prolonged mental harass- 
ment, physical exertion which is prolonged and excessive, and 
too little or improper food are conditions which apparently 
dispose one to it. 

Such intestinal parasites as bothriocephalus, ankylostoma, 
and, rarely, ascarides, cause the disease. It is also known to 
be due to malarial and syphilitic infection. Atrophy of the 
gastric glands, either with or without carcinoma of the stomach, 
is frequently associated with pernicious anemia and is suspected 



DIET IN DISEASES OF THE BLOOD. 329 

to be causative of it. In most cases an unusual amount of 
putrefaction in the contents of the intestine is demonstrable, 
and Hunter regards toxins thus generated as the cause of the 
disease. From the fact that iron is deposited in large amounts 
in the periphery of the liver lobules, as happens when corpuscles 
are experimentally destroyed in large numbers in the portal 
vessels, this theory seems plausible. 

Anemia of this kind develops not infrequently during or 
immediately after pregnancy, and it occasionally follows re- 
peated hemorrhages. 

Treatment 

So far as it is possible the conditions that predispose to per- 
nicious anemia and the infections that cause it must be removed 
or counteracted. 

Ferruginous preparations are of little value; this is also true 
of bone-marrow, which was widely used a few years ago. 
Transfusion of blood has given negative results in almost every 
case. The drugs which produce positive effects and possess 
real value in the treatment of the ailment are arsenical 
preparations and intestinal antiseptics. 

Those foods should be chiefly used which are least liable to 
putrefy in the intestine. Milk is the best. It should form 
the basis of all food for these patients. As the disease is 
chronic, the diet must be varied somewhat. During the periods 
of greatest severity a milk diet may be maintained for a week 
or ten days. It may, as improvement begins, be supplemented 
by eggs and by meat from which fat and most of the con- 
nective-tissue fibers have been removed, or in which they are 
least abundant, as in squab, young chicken, fish, and oysters. 
Stale bread, oranges, stewed fruits, and fruit-juices are also 
permissible. From time to time, and especially in the mildest 
cases and when improvement is progressing, the diet can be 
varied much more t) an this. 

Patients should be urged to drink water freely in order to 
dilute toxins and eliminate them rapidly. The bowels must be 
made to move regularly and copiously. The mouth and teeth 
must be kept scrupulously clean. 

Now and again, anorexia or nausea and vomiting interfere 



330 LEUKEMIA. 

with the administration of as much food as is needed. It is 
sometimes best to give the stomach a rest for a few days and 
to feed by the rectum. Lavage helps in many cases, especially 
when there are structural lesions in the stomach. A disincli- 
nation for food is best overcome by administering a little, often. 
Milk is then the best food. It should be given every two hours 
in portions of from one glass to half a glass or less. In these 
cases the administration of a sufficient amount of food is very 
difficult. Recourse must often be had to the employment of 
aids to digestion such as pepsin, hydrochloric acid and diastase, 
or predigested foods must be used. 

Patients should be kept quiet upon the bed or couch. If 
it is necessary to move them, in all severe cases this should be 
done by the nurse. Active exertion on their part not only 
exhausts them, but, because of the feebleness of the heart, is 
often dangerous. 

They should be kept in large, well-ventilated rooms, or, if 
the weather permits, out-of-doors. Sponging, an alcohol bath, 
and gentle rubbing are grateful and useful. Patients must be 
wrapped in warm clothing, for they feel the cold keenly, and 
are especially liable to those maladies which are caused by 
exposure to cold and dampness. 

LEUKEMIA 

This disease is characterized by a great and progressive in- 
crease in the number of white corpuscles of the blood and simul- 
taneous diminution in the number of red corpuscles. The 
lymph glands and spleen are usually enlarged and the bone- 
marrow is pathologically altered. 

Three varieties of leukemia are recognized clinically: the 
splenic, the lymphatic, and the medullary, according as the 
spleen, lymph glands, or medulla is chiefly affected. The 
spleen is almost always enlarged, but in some cases is so large 
as to fill more than half of the abdomen. Such cases belong 
to the splenic group. The lymph glands are usually somewhat 
enlarged, but in certain cases are enormously increased in size 
and the spleen is only moderately large. Such cases belong to 
the lymphatic group. When tender spots, and especially soft 



DIET IN DISEASES OF THE BLOOD. 33 1 

spots, can be found on the surface of long bones, they are 
regarded as evidence of the involvement of the bones in the 
disease, and the cases are classed as medullary. Better proof 
of the involvement of the medulla of the bones is disclosed 
by microscopic examination of the blood, for in such cases 
nucleated red corpuscles, polynuclear eosinophiles, mast-cells, 
and myelocytes are sure to be numerous. 

The progressive anemia produces a sallow pallor of the face 
and mucous membranes. It causes feebleness, shortness of 
breath, and rapid heart action on slight exertion. 

The onset of the disease is insidious and its progress usually 
slow. Acute cases exceptionally run their couise in a few 
days or weeks. 

Feebleness, or anemia, or deformities due to enlarged lymph 
glands are usually the first symptoms to bring leukemic patients 
to a physician. Later, lack of appetite and increased thirst 
are common symptoms. Digestion grows feeble as other 
bodily functions do. A little and variable rise of temperature 
is common in chronic cases. Metabolism is disturbed, for the 
elimination of uric acid is increased. Hemorrhages may take 
place from any of the mucous membranes. Inflammation of 
various viscera are common complications. Occasionally 
stomatitis develops and makes eating difficult. 

Causes 

The cause of leukemia is unknown. In so considerable a 
number of cases it follows malaria, syphilis, or injury of 
bones or of the spleen that these conditions have been regarded 
as causative. It sometimes develops after or during pregnancy 
or follows scrofulosis, rachitis, or chronic diarrhea. It recurs 
with frequency in successive generations of certain families, 
and has therefore been regarded as at times inherited. It 
has been suspected to be due to a specific infection or to 
autointoxication, but there is no evidence that either suspicion 
is correct. 

Treatment 

The disease is regarded as incurable, although very rare 
instances have been cited of recovery from it. 



332 LEUKEMIA. 

Medication must be addressed to symptoms, as no specific 
treatment is known. Desiccated spleen and lymph glands, 
as well as bone-marrow extract, have been tried, but un- 
availingly. Arsenical preparations, especially the organic 
arsenicals (cacodylic acid and its salts), often do good for a 
time when the number of red corpuscles is small. Exposure 
of patients to the x-tslj also does good and sometimes seems to 
effect a cure. 

Good hygiene and careful dieting will prolong life. There 
are often long periods of quiescence or improvement. 

An outdoor life should be insisted upon, if possible. At 
the same time, exercise should be taken in moderation, and 
in severe cases complete rest is often necessary. Patients should 
be guarded against the frequent inflammatory troubles that 
complicate the malady, and that are seemingly due to exposure, 
to cold, and dampness. 

Thirst should be satisfied with pure water, milk, and fruits. 
As appetite is usually lessened, pains should be taken to place 
food before these patients in as tempting a manner as possible. 
The food should be of a character that makes it easy to take. 
Often it is advisable to give some liquid nourishment, chiefly 
milk or egg and milk, every two hours in addition to what little 
food is taken at mealtimes. As digestion is impaired, only 
easily digested food should be taken. Milk, eggs, breast 
of squab and chicken, lean cold boiled ham, scraped or finely 
chopped beef, oysters, fish, stale bread, lettuce, spinach, boiled 
celery, green peas, oranges, stewed fruits, jellies, and fruit- 
juices are the best. In mild cases, when digestion is good, the 
diet may be much more varied than this. 

In those rare cases in which stomatitis develops, only the 
blandest foods, such as milk, custards, gelatin jellies, arrow- 
root, and similar articles can be eaten. Sometimes it is 
necessary for a few days to feed a patient exclusively by the 
rectum. 

The spleen becomes so large in some instances, and the stom- 
ach so compressed by it, that only a small amount of nourish- 
ment can be taken at a time. It is best under these circum- 
stances to give food which is not bulky, and to give it in small 
amounts frequently. Scraped beef, oysters, a raw or soft- 



DIET IN DISEASES OF THE BLOOD. 333 

cooked egg, somatose, and similar preparations are useful. 
Often feeding by the mouth must be supplemented by rectal 
feeding. A nutritive enema of milk (peptonized) and starch, 
with a pinch of salt, is the best. 

Inunctions of oil are important adjuvants to food taken by 
the mouth, when only small amounts are eaten. 

In all cases in which the administration of food is much 
restricted loss of strength must be prevented as far as possible 
by rest. 

The chemical state of the stomach juice in leukemia has not 
been studied. Clinically it has rarely been necessary to give 
hydrochloric acid or pepsin. An adjustment of food to the 
power of the stomach to do its work is most important. It 
is probable that motor inactivity is greater than chemical 
inactivity. 

Commonly, laxatives must be administered to insure com- 
plete bowel movements and good stomach peristalsis. 

PSEUDOLEUKEMIA 

This disease does not require extended description, as its 
dietetic and hygienic treatment must be the same as for leuke- 
mia, which it resembles clinically, except that the increase in 
white corpuscles is less pronounced and the demonstrable 
morbid changes are more markedly glandular. When swal- 
lowing is mechanically interfered with by enlarged glands, 
artificial feeding may be necessary. 



CHAPTER VIII 

DISEASES OF THE CIRCULATORY ORGANS 

Acute Pericarditis and Endocarditis. Acute Dilatation. Weak 
Heart. Palpitation. Angina Pectoris. Aneurysm of the Aorta. 
A rteriosclerosis. 

ACUTE PERICARDITIS AND ENDOCARDITIS 

These affections demand no dietetic treatment. They are a 
part of some general disease, such as rheumatism and the ex- 
anthemata, or of a local infection and toxemia, such as diph- 
theria or tonsillitis. The diet that is indicated for the principal 
malady must be adhered to when these cardiac complications 
arise. During convalescence care must be taken to avoid in- 
creasing the blood pressure unduly by drinking too much or by 
overloading the stomach and bowels. In these ways the 
heart, already weakened by the acute affection from which it 
has suffered, may easily be dilated or tired. The diet should 
be nutritious and concentrated. The bowels should be regu- 
larly and thoroughly moved. 

ACUTE DILATATION 

Acute dilatation of the heart requires complete rest and an 
abstemious diet. It is especially necessary to restrict the 
amount of fluids taken so that the heart and blood-vessels will 
not be overfilled. A dry diet and frugal fare, such as tender 
lean meat, dry bread or toast, and a minimum of milk or water, 
should be adhered to for a few days. Such a regimen cannot 
long be maintained, nor is it long necessary. As a rule, the 
heart rapidly contracts. When it approaches its normal di- 
mensions a variety of simply prepared foods may be permitted, 
but the quantities given must be small or moderate. The 

334 



WEAK HEART. 335 

bowels must be moved regularly and thoroughly. The dietetic 
regimen is designed to lessen arterial tension and cardiac work. 
Rest, followed by graduated exercise, and sometimes cardiac 
and general tonics, must be relied upon to effect a cure. 

Chronic dilatation of the heart can be treated in the same way. 
As its cause is rarely removable, a cure must not be expected, 
though great relief and a lessening of dilatation can often be 
effected. 

WEAK HEART 

Causes 

Asthenia arises from such lesions of the myocardium as 
pericarditis, chronic myocarditis, fatty degeneration and 
infiltration, from chronic and often progressive cardiac and 
aortic lesions, such as chronic valvular diseases of the heart, 
arteriosclerosis, and atheroma of the aorta, and from malnutri- 
tion such as will be caused by prolonged and high fevers and 
profound anemias. Many of these causative lesions cannot be 
removed, while some of them tend to grow gradually worse 
when once established. So long as the heart can be kept 
strong enough to do its work, these lesions do not affect the 
general health of the person in whom they have developed; 
or if a weak heart can be strengthened, so that its work may be 
resumed, a degree of recovery is effected and permanent 
weakness is averted. For all these cardiac maladies treatment 
is addressed to the preservation of muscular strength or to the 
improvement of the nutrition of the heart. The treatment of 
cardiac weakness is, therefore, the chief, usually the whole, 
treatment of chronic heart diseases. 

Frequently overexertion, either mental or physical, indiges- 
tion, constipation, or slight acute maladies give rise to the 
symptoms of cardiac fatigue, such as rapid heart-action or 
dyspnea, or both. This condition may be treated successfully 
and good compensation restored, provided the underlying 
lesion is not a progressive one. In other cases quick beating 
of the heart is constant, breathlessness is persistent, or at least 
is produced by exertion, and there are symptoms of passive 
congestion of certain organs, or edema, and often both. These 



336 DISEASES OF THE CIRCULATORY ORGANS. 

are cases in which the heart muscle is exhausted. Anemia is a 
frequent and serious complication of both groups of cases. 
Treatment 

When compensation for a valvular or other lesion is perfect, 
no special dietetic treatment is needed, unless the lesion is a 
progressive one, as when aortic valvular lesions grow out of 
aortic atheroma, or a stenosis exists that is likely to become by- 
degrees more pronounced. Moderation in diet, both quantita- 
tively and qualitatively, the choice of nutritious foods, the 
avoidance of alcohol, tobacco, and indigestibles, especially 
such as lobster, crab, and the like, that throw an undue burden 
on the depurative function of the liver, will prolong the period 
of maintained compensation. Milk should form a large pro- 
portion of the dietary, and water in sufficient quantity to main- 
tain good diuresis is necessary. The use of tea or coffee is 
usually to be avoided, but in individual cases may be permis- 
sible or even useful. When there is a progressive lesion, all 
physical overexertion must be avoided. Indigestion must be 
averted by scrupulous care in regard to eating. If gastritis 
exists, it must promptly be relieved. Fluids must be taken in 
moderation, and the bowels carefully regulated. At the same 
time, however, a nutritious diet is necessary, as there is often a 
tendency to malnutrition of the heart muscle. 

When arteriosclerosis and atheroma are the causative lesions 
of asthenia, all irritating foods and drinks, such as rich meats, 
rich gravies and sauces, and alcoholic beverages, must positively 
be forbidden. In such cases the kidneys are usually not sound, 
and elimination of nitrogenous waste is lessened; therefore a 
modified milk diet is the best. Not only is milk an important 
aliment, because it does not foster abnormal fermentations in 
the alimentary tract or produce renal or arterial irritants after 
digestion, but likewise is it an important diuretic, promoting 
the elimination of waste that otherwise would affect both 
arteries and muscles deleteriously. Milk, therefore, must be 
the staple food, although simply cooked vegetables, fruits, and 
stale breads are also permissible and commendable. Such vege- 
tables, however, as boiled cabbage, cauliflower, and baked beans, 
which digest slowly and are liable to cause flatulence, should 
be avoided. If the cereals do not cause the same disturbance, 



WEAK HEART. 337 

they may be eaten. In the cases in which the arterial and 
cardiac lesion is trifling, soft-boiled and poached eggs, fish, and 
oysters, rarely squab or the breast of chicken, may be per- 
mitted in small amounts and not oftener than once daily or once 
in two days. 

When compensation is broken and the symptoms of cardiac 
fatigue are manifest, the indications for treatment are to lessen 
the work that the heart has to do, and to improve its strength. 
Food judiciously administered may be made to meet both indica- 
tions. Rest, or graduated exercise, fresh air, sunshine, some- 
times hydrotherapy and medicinal tonics, are also needed. 

From what has already been said of the treatment of cardiac 
diseases, it is evident that in this group of cases digestive dis- 
orders must be prevented or corrected and an excess of fluids 
must be avoided in order not to tax the heart with an unneces- 
sary amount of work. It is equally essential that beverages 
shall not be taken in too small quantities, for if they are, blood 
pressure will be lessened too much and the heart will not work 
advantageously unless its muscle is stretched to some extent. 
This renders the use of a dry diet inadvisable, and indicates 
the moderate use of fluids. Only easily digested foods should 
be eaten; therefore fats, fried foods, pastries, hot breads, pan- 
cakes, cakes, entries, stews, rich sauces, and very sweet foods 
must be avoided. Moreover, only small portions of food should 
be eaten at a time, for overindulgence is especially harmful. 
A variety of simply prepared and easily digested food should be 
prescribed. Milk, kumiss, buttermilk, chicken, tender lean 
meat, oysters, eggs, stale bread, pulled bread, crackers, baked 
potato, peas, spinach, lettuce, oranges, and fruit jellies con- 
stitute a safe variety of food for the mild cases and for those 
which may be improving. 

Sometimes in this stage of heart weakness, but more fre- 
quently in the next, when the heart is exhausted, a chronic 
catarrh of the stomach complicates the ailment. Then the 
dietetic treatment appropriate for gastritis must be maintained. 
A milk diet, or slightly modified milk diet, is often at first the 
best. It may be gradually modified as the gastrin disorder 
lessens. It must be remembered that, as a rule, in cardiac 
diseases when the heart is weak, digestion is also impaired; 



338 DISEASES OF THE CIRCULATORY ORGANS. 

therefore the stomach, intestines, and liver must not be taxed 
unduly. Their strength must be preserved, well-digested and 
easily absorbed food being necessary to maintain cardiac and 
general vigor. When the heart is exhausted, a variable degree 
of passive congestion of the alimentary tract and liver exists. 
This interferes with the prompt absorption of digested foods 
and diminishes glandular secretion or the formation of diges- 
tive juices. Indigestion is, therefore, easily brought on, and is 
a complication in almost every case in greater or less degree. 
What has just been said of the exclusive use of easily digested 
foods, in moderate or small quantities, and of the avoidance of 
indigestible ones, is doubly applicable to such cases. If the 
liver is congested and comparatively inactive, sweets, excessive 
quantities of starches, and the red meats should be avoided or 
used with great moderation. 

Tissue change is often impeded because of incomplete oxygena- 
tion of blood and sluggish circulation in capillaries and lym- 
phatics. Diet, it is true, will not correct these conditions ; never- 
theless an accumulation of nitrogenous waste and of the products 
of abnormal fermentation in the alimentary tract increases the 
ill effects of such imperfect metabolism. This plainly shows 
that meats must be used sparingly, if at all, and gastrointestinal 
indigestion prevented. More can be done to correct faulty 
metabolism by graduated exercise, hydrotherapy, sunshine, 
and fresh air than by diet. 

When anemia exists, the diet may have to be modified so as to 
remove it. (See chapter VII.) 

The kidneys so often become incompetent because of passive 
congestion that the diet must at times be modified to meet this 
condition. A milk diet is then of great utility, as it stimulates 
diuresis and lessens the formation in the gastrointestinal canal 
of irritants that may be the cause of grave renal changes, and 
sometimes of mild toxemia or even genuine uremia. The 
greatest degree of renal incompetency occurs when the kidneys 
become waterlogged because of general edema. Then there is 
often almost a suppression of urine. Abstinence from bever- 
ages is unavailing to promote reabsorption of dropsical fluid, 
because the organs of elimination are no longer active. The 
drinking of milk and water tends to increase the dropsy. Diet 



WEAK HEART. 339 

will, therefore, not effect relief. Under such circumstances 
reliance must be placed upon incisions at the ankles through 
which the fluid filling the tissues may be drained, or upon drain- 
age effected by inserting numerous small metal tubes into the 
dropsical extremities. When anasarca is relieved, the kidneys 
once more become active. 

So long as dropsy is moderate and the kidneys are function- 
ally active it may be checked and frequently lessened by abstem- 
iousness in the use of fluids and of foods rich in water. If diaph- 
oresis and catharsis are at the same time provoked, it will be 
lessened with greater certainty. When anasarca is great, the 
fluid must be removed by the mechanical means just mentioned. 
It is also only in exceptional cases that dropsy into the ab- 
dominal cavity can be relieved by any other than mechanical 
means. 

Dyspnea on exertion is noticeable in the mildest cases of 
cardiac weakness, and constant and considerable dyspnea and 
cyanosis in the severer ones. It is a distressing and sometimes 
a dangerous symptom. It is commonly due to varying degrees 
of passive congestion. Asthenia, bronchitis, brown induration, 
of the lungs, edema, dropsy into the pleurae, pericardium, and 
abdominal cavity, gastric and intestinal distention, are the 
factors that aggravate it. Dietetic measures will effect little 
relief except when the dyspnea is largely due to gastric and 
intestinal distention. Flatulence must be prevented by avoid- 
ing overfeeding and especially by avoiding the amylaceous 
foods. Distention with fluids and solids may be prevented by 
limiting the quantity ingested and by stimulating their elimina- 
tion. 

Irregularity and rapidity of the heart's action are often pro- 
voked even in cases of moderate heart weakness, by slow diges- 
tion, by flatulence, and by constipation. These conditions 
must be corrected whenever the heart is excessively quick and 
irregular. 

It is the uniform testimony of clinicians writing upon heart 
diseases that it is best that alcoholics should not be used, or, if at 
all, very sparingly; the fermented beverages, being likely to pro- 
duce flatulence and sour stomach, should certainly be avoided 
entirely. Distilled beverages are sometimes used as stimulants, 



34° DISEASES OF THE CIRCULATORY ORGANS. 

but less often than formerly, because other drugs are more 
certain in their action and less liable to abuse. Tobacco must 
be forbidden when the heart is weak. It is especially likely 
to make it more irregular and more dilated. 

The need of preventing constipation has so frequently been 
referred to that it is hardly necessary to add emphasis. In 
these cases, diet does not help matters much, for the sweet 
fruits, sugars, and coarse breads, which are the most important 
laxative foods, are frequently counterindicated. 

When cardiac weakness is due to fatty infiltration of the heart 
muscle, as in cases of obesity, the diet described elsewhere as 
appropriate to that condition must be prescribed. 

PALPITATION 

Consciousness of rapid or irregular beating of the heart is 
often, but not always, caused by indigestion. Flatulence is 
especially likely to cause it. Overeating and indigestible foods 
must be avoided, especially the eating of such as lead to flatu- 
lence. Tea, coffee, and tobacco must also be forbidden. The 
bowels must be thoroughly and regularly moved. 

ANGINA PECTORIS 

Much can be done for the relief of angina pectoris by a dietetic 
regimen. A diet is indicated that will tend to lower the arte- 
rial tension and avert the formation, in the alimentary tract, of 
toxins provocative of high arterial tension. 

The first indication is met by abstemiousness as to food, and 
especially as to fluids. Only so much of fluids should be taken 
as is necessary to quench thirst, but not enough to distend the 
vessels. Meats ought to be used sparingly, and in some cases 
not at all. Meat-juices, broths, rich gravies, condiments, and 
alcoholic beverages are counterindicated. The first are most 
likely, because of indigestion, to produce toxins that will provoke 
arterial contraction. Some of the salts and extractives that 
they contain also heighten vascular tension. The bowels must 
be kept empty and gastric distention prevented, for otherwise 
arterial pressure will be raised. 



ANEURYSM. 341 

Mild cases of angina pectoris may be relieved and the attacks 
averted by such a regimen, and the avoidance of physical and 
mental fatigue, rapid motion, or exertion that causes noticeable 
effort. In severe cases the regulation of diet is all important. 
Tobacco should not be used; many find it necessary even to 
avoid rooms in which others are smoking. 

Often attacks which occur in those who have high blood 
tension due to more or less chronic indigestion and constipation 
are made better or are cured, at least temporarily, by taking 
exclusively six glasses of milk daily and by emptying the bowels 
thoroughly. After an exclusive diet of milk for a week ox 
more it may be modified by giving a glass or two more daily, 
and fruits either fresh or preserved. Later an egg in the milk 
or in the form of custard can be eaten and ice-cream can be 
substituted occasionally for the milk. Still later stale bread 
or pulled bread and such vegetables as peas, string-beans, 
spinach, lettuce or raw tomatoes can be eaten sparingly as an 
addition to milk. Very slowly the diet can be varied still more, 
but the need of eating small quantities and only the most digest- 
ible kinds of food, or at least kinds not liable to fermentation, 
must be kept constantly in mind. 

ANEURYSM OF THE AORTA 

When aneurysm exists, the middle coat of the artery is 
atrophied and often wanting over a part of the distended vessel. 
The inner coat sometimes shares the same fate. Rupture of the 
aneurysm is a result always to be apprehended. To avert this 
accident an increase of blood pressure must be prevented. 
When recovery takes place, it is effected by the thickening and 
strengthening of the wall of the aneurysm by the formation 
within it of a fibrinous coagulum that may ultimately become 
organized tissue. Diet has been regulated with the hope that 
coagulation of the blood within the aneurysm would in that 
way be promoted, but it is doubtful whether permanent good 
results can thus be effected. 

The quantity of fluid imbibed should be restricted, so that the 
aneurysm will not be distended by it. Only easily digested 
and moderate quantities of food should be eaten. If indiges- 



342 DISEASES OF THE CIRCULATORY ORGANS. 

tion exists, it must be corrected, and constipation must be 
relieved or averted. If the stomach and bowels can do their 
work well, a varied diet may be prescribed; but care must be 
taken to limit the quantity eaten. Indigestion and constipa- 
tion will, in a few cases, necessitate special diets. If atheromat- 
ous lesions and arteriosclerosis have led to the production of 
aneurysm, nitrogenous foods must be used sparingly. Milk 
is the best basis of a diet, but it cannot be used without restric- 
tions, or the arteries will be overfilled with fluid. It may be 
supplemented with cereals, breads, vegetables, fruits, and very 
limited quantities of egg t fish, oysters, and the breast of chicken. 

It is interesting to recall the regimen formerly prescribed for 
aortic and other aneurysms that could not be treated surgically. 
The treatment commonly called Valsalva's, as reported by 
Morgagni, was to " detain the patient in bed for forty days, and 
during this period to subject him to repeated bleedings, while 
at the same time the diet and drink were carefully ordered, so 
that the daily allowance, administered in three or four meals, 
should never be such as to fill up the blood-vessels. He made 
it a custom to diminish the quantity of meat and drink more 
and more every day till it was brought down to half a pound of 
pudding in the morning, and in the evening half that quantity, 
and nothing else except water, and this also within a certain 
weight. After having sufficiently reduced the patient by this 
method, so that, by reason of weakness, he could scarcely raise 
his hand from the bed in which he lay, the quantity of aliment 
was increased again by degrees until the necessary strength 
returned so as to allow of raising up." 

It is true that this regimen, or one approaching it, though 
not so severe, often has caused pain to lessen or to disappear, 
the aneurysm to become smaller and to pulsate less, but most 
patients have regarded the cure as worse than the disease. 
Tufnell devised a modification of Valsalva's regimen, which was 
often used. He did not bleed. He required rest in bed for 
eight or ten weeks at least. For breakfast he prescribed two 
ounces of white bread and butter, with two ounces of cocoa or 
milk; for dinner three ounces of boiled or broiled meat, with three 
ounces of potatoes or bread and four ounces of water or light 
claret; for supper, two ounces of bread and butter and two 



ARTERIOSCLEROSIS. 343 

ounces of milk or tea, making in the aggregate ten ounces of solid 
and eight of fluid food in twenty- four hours, "and no more." 

So restricted a diet is no longer believed essential to good 
treatment. An abstemious but nutritious one is. Rest in bed, 
or in mild cases the gentlest exercise, must be insisted upon. 
The iodids are almost universally relied upon to-day. Surgical 
treatment is inapplicable to aortic aneurysm, though some good 
results have followed electrolysis with the introduction of wire. 

During the last few years subcutaneous or intravenous injec- 
tions of gelatin have been used with success for they promote 
blood-clotting. Of course, the strictest care must be taken to 
prevent sepsis. A sterilized solution of 1 or 2 per cent, of 
gelatin in physiologic salt solution is the strength usually 
employed. As much as 5 per cent, has been used. Subcutane- 
ously, from four to eight ounces are injected at one time. The 
aneurysm pulsates less violently or ceases to do so altogether, 
and gradually contracts. Pain and pressure symptoms lessen 
or disappear. Failures follow this as they do other modes of 
treatment, but a sufficient number of successes have followed 
it to make it worth trying. In some cases the internal admin- 
istration of gelatin has been tried, and good results have been 
claimed for it. 

ARTERIOSCLEROSIS 

Causes 

Arteriosclerosis undoubtedly occurs generation after genera- 
tion in some families. It is admittedly most likely to develop 
in those who do exhausting physical and mental work. It is 
believed to be caused also by eating large amounts of nitrogen- 
ous foods. When high arterial tension is constantly present, 
the patient ought to be warned of the necessity of abstemious- 
ness in the use of meats, and especially the red meats, and 
encouraged to drink water and milk with sufficient freedom 
to maintain active elimination. Indigestion and constipation 
must be prevented. Excessive physical and mental work 
should be avoided. Habits of exercise, sleep, and eating must 
be regular. 



344 DISEASES OF THE CIRCULATORY ORGANS. 

Treatment 

When the arteries are distinctly sclerosed, greater care must 
be taken along the same lines. If possible, milk should form a 
considerable element of diet, vegetables, breads, cereals, fruits, 
and a modicum of eggs, fish, oysters, and the white meat of 
fowl may be used. 

The following menu for a day will suggest others: 

Breakfast. — An orange, a cereal, a glass of milk and an egg 
and one or two small pieces of bread or toast. 

Lunch. — A cream soup, bread, lettuce salad, water or milk. 

Dinner. — Fish, boiled potato, peas or string-beans, bread, 
a simple pudding or fruit. 

Meats, especially the red meats, such as beef and mutton, 
are the chief sources of alimentary toxins that are supposed to 
be often the exciting cause of the arterial lesion. In mild cases 
they may be eaten in small amounts occasionally, but not daily. 
They should not be used at all if headache, insomnia, nocturnal 
distress, sighing respiration, or other dyspnea suggests intoxi- 
cation by alimentary toxins. When these symptoms arise, a 
milk diet should be prescribed for a few days, or one slightly 
modified by the addition of cereals, breads, a small quantity of 
vegetables, and fruits. Such a diet will usually relieve the 
distress very soon. It need not be long continued, but meats 
should be used sparingly at all times. The necessity of eating 
moderately rather than heartily is greater in proportion as the 
lesions of the arteries become more and more considerable. 
At all times pork, 'high' game, meat stews, rich gravies, greasy 
soups, preserved meat, crabs, and lobsters must be avoided. 

Arteriosclerosis often leads to aortic, cardiac, or renal disease 
or to hemiplegias. These sequelae or complications sometimes 
modify the regimen that has been outlined. 



CHAPTER IX 
DISEASES OF THE KIDNEYS 

Nephrolithiasis. Albuminuria. Uremia. Passive Congestion 
of the Kidneys. Acute Nephritis. Chronic Diffuse Nephritis. 
Interstitial Nephritis. Pyelitis. 

NEPHROLITHIASIS 

The management of diet is of the greatest importance for the 
prevention of the formation of renal calculi. These stones may- 
be composed of uric acid, of oxalic acid, of the phosphates, or 
of two or all of these ingredients and much less frequently of 
other organic substances. Each variety requires an especial 
regimen. 

Calculi vary in size from almost microscopic crystals and fine 
sand to stones of large size. The former usually occurs as 
crystals of one kind, the latter as agglomerations of one or more 
kinds of crystals or of amorphous chemical substances. Calculi 
are often laminated, each lay T er consisting of a different sub- 
stance. The recent analyses of stones removed from the 
kidneys and bladder by Benjamin Moore 1 show that they con- 
sist commonly of a mixture of calcium oxalate, calcium phos- 
phate, and uric acid. Of these ingredients the former occurs in 
much the largest amount. 

Uric acid calculi are due to a persistent excess of uric acid 
in the blood and to an acid condition of the urine. The exces- 
sive, or sometimes the generous, use of nitrogenous food will 
cause both of these conditions. Necessarily, therefore, meats 
must be used sparingly by those liable to the formation of 
uric acid stones. It is usually possible for such patients to 
eat eggs, fish, oysters, and clams with safety. Even the red 
meats may be eaten, but in moderation, and not oftener than 

1 British Medical Journal, April i, 191 1. 

345 



346 DISEASES OF THE KIDNEYS. 

once a day. Other foods may be used as they are relished, 
provided that the stomach or the organs of digestion are 
not overtaxed. Indigestion ought to be prevented in every 
way possible. Water should be drunk copiously, not only in 
order to stimulate elimination by the kidneys, but also because 
drinking freely dilutes the salts of the blood and in that way 
helps to prevent their deposition in the kidneys. Inasmuch as 
water that is as free from mineral matter as possible is the best, 
distilled water or pure soft waters, such as the spring waters of 
Waukesha, which contain a minimum amount of salts, are to be 
preferred. The lithium waters, too, are often prescribed. The 
generous consumption of all these waters is beneficial, but all 
recent investigations show the inutility of lithium in these cases. 
It is true that the lithium compounds of uric acid are readily 
soluble and eliminable, but they are not formed in the blood 
when lithium is taken into the stomach. It forms in that organ 
very stable compounds with phosphoric acid, which are not de- 
composed in the blood. Saline waters, such as come from the 
Vichy and Geyser Springs of Saratoga, and from Vichy, Vals, and 
Kissingen Springs of Europe, are often used with advantage by 
those who have indigestion. The stronger saline waters, such as 
can be obtained at West Baden springs in Indiana, Congress and 
Hathorn Springs of Saratoga, and at Carlsbad in Bohemia, are 
useful for the same class of patients, especially when the latter 
are stout. But these saline waters should not be recommended 
to those who are weak, neurasthenic, or anemic. 

A residence at a spa is advantageous because of the change of 
scene, of food, and of mode of life that it insures. The freedom 
from care and continuous work, and the outdoor exercise in- 
cidental to it are often important elements of cure, aside from 
the fact that more water is drunk there than at home. 

Moderate, regular exercise in the open air is necessary to pro- 
mote good digestion and assimilation. Hot baths and friction 
of the skin are advantageous for the same reason. The use of 
alcoholic beverages should be forbidden. 

Oxalic acid calculi are caused by eating vegetable foods rich 
in this acid, which must consequently be forbidden. The 
commonest articles containing oxalic acid are rhubarb, sorrel, 
tomatoes, tea, spinach, cabbage, and celery. The use of the 



NEPHROLITHIASIS. 347 

following vegetables and fruits is also prohibited by some 
clinicians: turnips, onions, apples, pears. 

Indigestion is as essential for the formation of these calculi as 
the presence in the stomach of food containing oxalic acid. 
Indeed, it is claimed by some chemists that bacteria can pro- 
duce the acid out of sugar, starch, and cellulose. Prevention 
and correction of indigestion are more important to effect a 
cure than the withdrawal of the foods just named from patient's 
dietary. 

Only simply cooked food should be eaten. Animal foods, 
dry bread, and milk should form the staple articles of diet. 
Fats and fried foods should be avoided ; tea, coffee, and alco- 
holic beverages likewise. Water ought to be used with the same 
freedom as in cases of uric acid calculi, one and a half or two 
quarts of liquid being drunk daily. What has already been 
said of mineral waters and a residence at springs for those 
suffering from uric acid calculi is applicable also to these cases. 
Exercise and an out-of-door life, and freedom from anxiety 
and care are equally necessary to success of treatment. The 
character of the digestive disorders that underlie the ailment 
usually affords indications that govern the details of treatment. 

Phosphaturia will occur only when the urine is persistently 
alkaline or nearly so. As a vegetable diet is most likely to 
cause this condition, a diet consisting chiefly of meats, breads, 
cereals, and milk is to be preferred. Water is quite as neces- 
sary as in other varieties of renal calculi. Chronic cystitis and 
pyelitis which commonly produce alkaline fermentation in the 
bladder or renal pelvis are especially apt to be accompanied by 
the formation of phosphatic calculi. When these conditions 
exist they must be corrected by appropriate treatment. 

As lime forms the base of many calculi it is also important to 
forbid the use of beverages and food containing it in large 
amounts. Hard water, milk and milk products are the com- 
monest sources of this element in any considerable quantity. 
Therefore hard water should be forbidden and milk and milk 
products should be eaten abstemiously. 

Such hygienic and dietetic directions as have been prescribed 
for these cases usually will not effect the removal of large 
calculi, but they will prevent the formation of new stones or the 



34§ DISEASES OF THE KIDNEYS. 

enlargement of old ones. Drinking water very copiously will 
often effect the removal of fine crystals, or renal sand, as they 
are sometimes called, from the pelves of the kidneys. 

When renal colic is caused, opiates and anesthetics must be 
employed to relieve the pain. In the mildest cases rest, 
counterirritants, or hot applications are helpful, and are, in- 
deed, sufficient to bring about a cure in some instances. 

ALBUMINURIA 

Albuminuria of renal origin is due to passive congestion or to 
inflammation, except in certain anemias, cachexias, and fevers, 
when the structural change in the kidneys is a degenerative one. 
It has been urged that in some cases the albumin of the blood 
was in unusual combination, so that elimination by the kidneys 
was possible, although these organs were not structurally 
changed, and the following facts have been advanced to sustain 
this view — namely, that raw egg-albumen introduced into the 
blood by intravenous or hypodermic injection, or even much of 
it by the stomach, provokes an albuminuria, while cooked egg- 
albumen does not do so when taken into the stomach. Although 
this observation may be correct, it is found, in practice, that 
whenever albumin is demonstrable in the urine either continu- 
ously or intermittently, there are structural changes in the 
kidneys. It escapes from the glomeruli with the water of the 
urine. If any finds its way into the tubules through their walls 
it is insignificant in amount, except when a hemorrhage occurs 
sufficiently great both to fill the interstitial spaces and to rupture 
some of the tubules. Therefore in the cases of albuminuria 
ordinarily met with, structural changes exist in the glomeruli. 

As a rule, casts are found in urine when albumin is of renal 
origin. They are sometimes few in number as compared to the 
amount of albumin, but they can be found, being formed, 
within the tubules, of material secreted by or made from the 
epithelium. Epithelial cells, as well as blood-corpuscles, are 
often embedded in the casts, and still oftener the granular debris 
caused by their disintegration may be seen in them. Casts are 
very commonly met with when much abnormal fermentation 
occurs in the gastro-intestinal tract and when the liver is in- 



ALBUMINURIA. 349 

active. Albumin is not always found in these cases, although in 
most instances a trace of it can be demonstrated in the urine 
from time to time. Frequently also casts can be found in the 
urine before albumin appears, when there is slight chronic 
renal congestion. Toxins produced by gastro-intestinal in- 
digestion cause casts to appear in the urine because the kidneys 
are irritated by them and the function of the epithelium is 
modified. Several glasses of beer, or equivalent quantities of 
other alcoholic beverages, taken at one time will cause casts to 
be formed, and for the same reasons. The fact that gastro- 
intestinal indigestion at times causes slight transitory albumin- 
uria is of importance as a guide to its prevention and treatment. 

Albuminuria in febrile maladies is due in part to the presence 
of toxins in the blood, which must be eliminated through the 
kidneys, and in part to those structural changes called cloudy 
swelling, that are so common in these cases. Even in fevers 
regular and copious bowel movements are necessary to prevent 
albuminuria, as every watchful clinician has had occasion to 
observe. Casts become more numerous, more granular, and 
albumin is more constantly present when the intestines are 
clogged with fecal matter. 

Abuminuria is aggravated not only by digestive disorders, but 
also by certain foods. Several raw eggs or a good meal of meat, 
especially such as is very rich in extractives, will usually in- 
crease the percentage of albumin in the urine. Mental and 
physical fatigue likewise aggravate albuminuria possibly by 
causing the rapid production of waste-products that must be 
eliminated by the kidneys. 

Intermittent albuminuria and cyclic albuminuria are forms in 
which it occurs at regular or irregular intervals, but does not 
affect the general health of the patient. The amount of al- 
bumin voided is small. It is caused to appear either by phys- 
ical exertion or by eating albuminous foods. To prevent the 
appearance of albumin in the urine in such cases it is not neces- 
sary, as a rule, to forbid its use altogether. It is possible to eat 
an amount, which must be determined by trial. Those cases 
in which physical exertion is the chief or only cause of albu- 
minuria cannot be relieved very easily. 

Certain nitrogenous foods are more likely than others to cause 



350 DISEASES OF THE KIDNEYS. 

albumin to appear in the urine. Milk, although it contains from 
4 to 5 per cent, of protein, is the food par excellence for those 
who have albuminuria. If eggs are eaten raw, albumin is more 
likely to appear or to be increased in the urine than when they are 
used after cooking. Fish and oysters affect only the severe 
cases unfavorably. The meat of squab and the breast of chicken 
are believed by many to be less harmful than the red meats, 
such as beef and mutton. Breads, cereals, vegetables, and 
fruits may be eaten by most of those having albuminuria. The 
use of these articles of food must be curtailed because of uremia, 
severe nephritis, or complicating disorders of digestion, not be- 
cause of albuminuria. 

Water and other permissible liquids should be drunk copiously, 
eight to twelve glasses daily, when casts, renal epithelium, 
blood-cells, or granular matter, as well as albumin, appear abun- 
dantly in the urine. As in such cases the urine is diminished in 
amount, diuresis must be provoked by drinking water freely. 
Milk also is almost a necessity in the treatment of these cases, 
both because it is a perfect food and because it is a diuretic of 
great value. Tea, coffee, and cocoa may be permitted in the 
mildest cases provided they do not hinder or disturb digestion. 
Alcoholic beverages must be forbidden when any portion of the 
urinary tract is inflamed or diseased, for they aggravate such 
conditions. 

The details of dietetic treatment in the common cases of 
albuminuria can best be described in connection with the sub- 
jects of passive congestion of the kidneys and of nephritis. 

UREMIA 

Uremia, or renal insufficiency, demands the most careful 
regulation of diet. The toxins that provoke it are produced in 
small part by the metabolism of living cells, but chiefly by 
fermentation in the stagnant contents of the intestines, or by 
common ingredients of food, such as potassium salts, which 
probably play a part in uremic intoxication. These are de- 
rived directly from the food and can be excluded from the body 
by a regulation of diet and by emptying the intestines. Cathar- 
sis must be provoked, so as to remove from the bowels all 



UREMIA. 351 

fermenting and toxic matter. For this purpose elaterium, 
calomel or salts can be prescribed. If a patient suffers from 
uremic mania, from acute uremia, or from symptoms of mild 
uremia that are becoming severer, all food should be forbidden 
for thirty-six or forty-eight hours, but water should be given 
as freely as possible. If unconsciousness prevents its being 
swallowed easily, it should be given by the rectum or sub- 
cutaneously, so that diuresis will be aided as much as possible. 
Cathartics should also be given so as to empty the bowels as 
rapidly and as completely as possible. No treatment is more 
effective than this. When the uremic symptoms have disap- 
peared, food may be given, but the amount and character of it 
should be prescribed with care. To begin with, water gruel 
made of arrow-root or rice is sometimes recommended. It is 
rarely necessary to do this. It is better to give no food until the 
symptoms of uremia are gone, and then to begin by giving 
milk. At first a half glass every two hours may be given. The 
amount should gradually be increased to a full glass. Milk is an 
ideal food in these cases, for it contains a minimum of toxic 
matters, is not likely to ferment in the intestines, and is a valu- 
able diuretic. Care must still be taken to make the bowels 
move freely. When the volume of urine voided approaches the 
normal average, starches and sugars may also be given. For 
example, rice, breads, potatoes, and many fruits may be used to 
supplement, not to displace, the milk. If improvement con- 
tinues, vegetables may also be permitted to form a part of the 
diet. Albuminous food should not be used so long as the daily 
excretion of nitrogenous waste is much below the average for one 
on a milk or a modified milk diet. In an acute nephritis it should 
not be used so long as there is albumin in the urine ; in chronic 
cases not while the urine contains much sediment, numerous 
casts, epithelial and blood-cells, or granular matter. When 
proteins are added to the diet, it is best to begin with fish and 
soft-cooked eggs; later, to add squab, breast of fowl, and, 
when recovery is complete, the red meats and game. Protein 
foods should be given at first in small portions, and their effect 
upon the amount of urine, urea, and albumin voided should be 
watched carefully. In the same way the effect of larger amounts 
and of different kinds of foods should be studied. 



352 DISEASES OF THE KIDNEYS. 

So long as large quantities of milk are taken daily it is not neces- 
sary to urge the drinking of water, but when the diet is varied 
and the amount of milk taken is lessened, it is best to prescribe 
the drinking of approximately two quarts of fluid, preferably 
milk and water. A little tea or coffee, and milk soups, may be 
permitted in many instances. 

It is equally necessary to keep the intestines well emptied, the 
skin clean and active, and the lungs filled with pure air. This 
disease should be treated in large, well-ventilated rooms. The 
patient must be protected from drafts and from cold by suitable 
clothing. Hot baths and friction of the skin are imporant aids 
to treatment. 

In all cases of uremia as complete rest as possible should be 
enjoined. 

PASSIVE CONGESTION OF THE KIDNEYS 

The regimen in these cases is chiefly dictated by the primary 
disease that causes the congestion. As a rule, when passive con- 
gestion of the kidneys exists, digestion is also slow and imperfect, 
often because of congestion of the organs of digestion. Conse- 
quently only the simplest and most digestible foods should be 
eaten. Diuresis should be promoted, which is always best 
accomplished by given water copiously. The kidneys are not 
infrequently edematous as well as congested. 

While there is little danger of uremia developing in uncom- 
plicated cases of passive congestion of the kidneys, a nephritis 
following the congestion may cause it. To avert nephritis the 
role that irritating foods and the products of fermentation within 
the intestines play in producing it must be remembered. For 
this reason the bowels should not only be well emptied, but 
care should be taken to keep them so, and to give the patient only 
those foods that are not irritating to the kidneys. In severe 
cases, and when there is danger of nephritis, an exclusive milk 
diet is the best. Medical treatment must be resorted to in order 
. to relieve passive congestion. In most cases the heart must be 
strengthened by appropriate tonics. Complete rest is an essen- 
tial element of treatment. 

Sometimes a brief period of starvation (drinking water may 



ACUTE NEPHRITIS. 353 

be permitted) and catharsis relieves renal congestion more 
promptly than any other form of treatment, especially is this 
true when there also is passive congestion of the liver. 

ACUTE NEPHRITIS 

Causes 

Nephritis may be produced experimentally by swallowing, in- 
haling, or otherwise introducing into the blood certain chemicals, 
such as salts of arsenic, lead, chromium and turpentine and some 
other oils that are renal irritants and that must be eliminated 
by the kidneys. Cases of Bright's disease of this origin 
are rare. Nephritis is, as a rule, due to other causes; chiefly 
to infection and the elimination of toxins by the kidneys. 
Sometimes the microbes causing an infectious disease are 
themselves the direct cause of nephritis ; more frequently they 
are a cause, but not the only one, for toxins generated by abnor- 
mal fermentation within the gastrointestinal tract are among 
the most important provocatives of this lesion. If digestion 
has been undisturbed and defecation perfect prior to the onset of 
diphtheria, scarlet fever, and similar diseases, and if the stom- 
ach is not overloaded after the disorder starts, and the intestines 
are regularly and thoroughly emptied, nephritis is of rare 
occurrence. The importance of the condition of the alimentary 
organs in the production of nephritis in scarlet fever is em- 
phasized by the observations of Jaccoud, who found that a 
milk diet maintained during an attack of scarlet fever, and for 
two or three weeks after, was a very certain preventive of renal 
complications. 

Those infections that are almost always accompanied by 
nephritis, such as yellow fever and cholera, are diseases in which 
pre-eminently the contents of the gastrointestinal tract are in 
a state of abnormal and excessive fermentation. In those 
diseases the infectious agent is undoubtedly the cause of the 
alimentary disorder. The nephritis is chiefly, if not wholly, 
due to the toxins that it produces in the intestines. Micro- 
organisms, however, sometimes play a part in causing the 
renal inflammation. They are often eliminated, both dead and 
alive, in the urine ; but the number found in it does not always 
23 



354 DISEASES OF THE KIDNEYS. 

bear relation to the degree of irritation of the kidneys, when 
any exists. Numerous colon bacilli and typhoid bacilli have 
been found in urine that does not contain albumin or other 
evidence of structural disease of the kidneys. Structural 
diseases of these organs, however, producing albuminuria and 
renal tube-casts, are common in typhoid fever, but are evidently 
not due solely or chiefly to contact of the bacilli with the 
kidneys. 

Exposure to cold and wet is frequently named as a cause of 
acute nephritis. Good clinicians, however, have doubted the 
accuracy of this view. The rheumatoid diseases are undoubt- 
edly produced by such exposure, in the presence, that is, of a 
peculiar state of the blood or of nutrition, but rarely are com- 
plicated by nephritis. It is also quite conceivable that acute 
nephritis may be caused by cold, providing the blood is filled 
with irritating toxins. However, it is evident, at all events, 
that the prevention of fermentation within the alimentary 
tract is of the utmost importance if nephritis is to be averted. 

Unquestionably the character of food plays a part in causing 
renal diseases. The extractives of the richest meats are irritants 
that may aggravate albuminuria or help to produce it. The 
toxins produced by putrefaction of albuminous foods are more 
irritating than are the products of fermentation in other foods. 
Different meat foods vary as to the amount of toxins that they 
contain or can produce. Those that are least likely to ferment 
and are quickest digested are the blandest. No food has been 
found so well adapted to prevent nephritis or so suitable to the 
needs of a patient during its course as milk. Now, milk con- 
tains 4 per cent, of albumin; eggs, approximately 5 per cent.; 
and bouillon, 2 per cent. ; but while either of the last may aggra- 
vate an albuminuria, the former will not. It is, therefore, not 
alone the percentage of protein that a food contains that makes 
such food more or less detrimental in nephritis, but its kind 
and its association with other ingredients, such as extractives. 
Treatment 

When a case of acute nephritis first comes under treatment, it 
is best to enjoin rest in bed, to withhold all food for twenty-four 
or thirty-six hours, to give water freely, and to empty the ali- 
mentary canal by provoking purgation. Then milk should be 



ACUTE NEPHRITIS. 355 

given — at first in small quantities, at intervals of two hours. 
The quantity must be increased gradually until two quarts are 
taken daily. Milk is especially adapted to be the sole diet of 
those who have acute nephritis, because it more nearly meets 
the demands of the system than any other single article of food. 
It is nutritious, quickly digested and absorbed, and therefore 
not likely to ferment in the stomach or bowels, and it possesses 
important diuretic properties. 

Unfortunately, some patients cannot take milk with comfort 
or pleasure. This intolerance is often lessened or removed if, 
when the diet is begun, milk is administered in very small 
amounts, — one or two ounces at a time, for example, — and if the 
amount is slowly increased. Moreover, it is less likely to 
produce gastric distress if it is sipped instead of being drunk 
rapidly. 

Milk is not palatable to some patients, and occasionally the 
attempt to force it upon them will cause so great disgust as to 
necessitate its discontinuance. Under these circumstances a sub- 
stitute must be found. Many individuals who will not drink 
plain milk will take it when it is seasoned with pepper and salt, 
or is warmed, or is added to gruel, and sweetened. Salt is often 
harmful in nephritis. Much of it irritates the kidneys and 
its retention in the tissues sometimes helps to cause edema. 
Corn-starch, tapioca, and rice make dishes that are palatable 
with milk. They often enable one to give much of it without 
offending the sense of taste. Fruits may also be given with it. 
One must remember, however, that in proportion as the diet is 
varied, the danger of fermentation in the intestines is increased. 
If milk can be taken only in small quantities with other foods, 
it is necessary to see to it that water is drunk to supplement it, 
so that at least two quarts of fluid are taken daily. 

The best adjuvants to milk in these cases are the starches and 
sugars, rice, corn-starch, tapioca, bread, boiled macaroni, baked 
potato, sweet fruits, and fruit-juices. After the preliminary 
period of withholding food, a water gruel may be given instead 
of milk. If the disease pursues a favorable course, more and 
more varied foods of the character just described may be used. 
It is, however, the universal judgment of the profession to-day 
that there is in this disease no perfect substitute for a milk diet. 



356 DISEASES OF THE KIDNEYS. 

When the urine becomes copious and the amount of nitrog- 
enous matter voided in twenty-four hours is all that is to be 
expected, farinaceous foods may be prescribed in addition to 
milk. In a few days some of the sweet fruits and simpler 
vegetables may be given. When albumin disappears from 
the urine, an egg may be tried. During the time that 
albuminous foods are being added to the patient's dietary, 
close watch must be kept upon the effect of it — that is, upon 
the quantity of urine, the amount of daily nitrogenous excre- 
tion, and the amount of albumin and number of tube-casts, if 
any are found, in the urine. 

When an egg can be eaten without harm, white meats may be 
tried, such as the breast of squab and chicken, a little boiled 
ham, or perfectly fresh fish. Red meats, rich in extractives, 
should not be eaten until recovery is established. 

In some cases the stomach is intolerant at the onset of the 
disease. Water must then be given hypodermically and by 
the rectum to insure sufficient renal elimination. It may also 
be necessary to give some predigested milk by the rectum. As 
a rule, when the bowels are well emptied and the kidneys begin 
to ehminate more urine, vomiting ceases, for renal congestion 
and suppression of the functions of the kidneys are its cause. 

So long as there is edema, a patient should be kept in bed. 
During the entire course of the disease he should be protected 
by warm clothing from sudden chilling of the skin. While he 
should be supplied with an abundance of fresh air, it should be 
kept at a uniform and genial temperature until recovery is 
established. 

The activity of the skin can be promoted with benefit by 
rubbing it and by warm or hot baths. 

Many mild cases need little medicine except a laxative at 
first, and its repetition occasionally during their course. 
Others require both careful hygienic and medicinal treatment. 



CHRONIC DIFFUSE NEPHRITIS 



Causes 



The influence of overeating and of injudicious eating in 
producing chronic nephritis is so generally appreciated that it 



CHRONIC DIFFUSE NEPHRITIS. 357 

scarcely needs discussion. Chronic diffuse nephritis, like 
acute nephritis, is oftenest due to infection. It sometimes 
grows out of acute nephritis, or is produced by the same in- 
fectious diseases, or it arises from chronic suppuration, malaria, 
and syphilis. Formad's statistics have made it evident that 
it is this form of nephritis that the prolonged and excessive 
use of alcoholic beverages produces. They provoke albu- 
minuria by exciting structural changes in the glomeruli, and even 
before they cause it they often cause casts to appear in the 
urine by perverting the secretions of the renal epithelium or 
by destroying its cells. Nephritis in a drunkard is, however, 
due in part to the deranged condition of stomach and bowels, 
and only in part to alcohol directly. 

Treatment 

In chronic diffuse nephritis there are the same indications for 
a milk diet as in acute nephritis. It is, however, so prolonged 
a sickness that an exclusive milk diet cannot be maintained 
continuously. When acute exacerbations occur, as they often 
do, a milk diet for a short time is as necessary as in acute 
nephritis. Although a strict milk diet has been commended, 
and by some clinicians urged as a necessity in these cases, there 
is evidence that some patients do not do so well upon it as 
when a more varied diet is permitted. 

An exclusive milk diet may advantageously be prescribed 
intermittently in some instances, milk alone being taken for 
two or three weeks, then a modified milk course or mixed diet 
for a like time. The numerous mild cases of chronic diffuse 
nephritis can best use what may be called a modified milk diet 
or a carefully selected mixed diet. By a modified milk diet, 
I mean one of which the basis is milk, and from which meats, 
fish, and eggs are excluded, while bread, starches, fruits, and 
vegetables torm a part. By a selected mixed diet I mean one 
that contains meats, eggs, and fish, but only a prescribed 
amount of selected kinds of meat and fish. Breads, gruels, 
and the most digestible flour products are permissible. The 
use of butter and cream is to be recommended. Potatoes, peas, 
beans, and green vegetables in general may be eaten, as may 



35& DISEASES OF THE KIDNEYS. 

fruit jellies, compotes, and fruits. Some clinicians forbid 
cabbage, sauer-kraut, asparagus, spinach, and artichokes 
because of the large amount of potassium that they contain. 
Rhubarb, sorrel, and tomatoes are also forbidden, because of 
the oxalates that are in them. Oxalates, however, are less 
likely to cause trouble in diffuse, than in interstitial nephritis. 

Bouillon, meat extracts, and meats rich in extractives, such 
as beef, must be forbidden, because of the toxins in them or 
easily generated by them. 

There is much difference of opinion as to the availability of 
different albuminous foods in this disease. Egg-albumen is the 
least harmful of any. Tessier contrasts their effect on cases of 
albuminuria in this way: "Fish which is not quite fresh and a 
little of cheese will cause albumin to reappear when two to 
four eggs and a slice of ham will not." 

Next in degree of innocuity can be placed squab, breast of 
chicken, ham, cold porik, and lamb. The effect of fish upon albu- 
minuria is disputed. It is probable that the difference of 
opinion is due to the varying qualities of the fish experimented 
with. They quickly change when killed, and neither odor nor 
taste always reveals their condition. If perfectly fresh, they 
are probably as harmless as any meat. If they are ever so 
slightly tainted, they contain renal irritants. Oysters and 
frogs' legs are also permissible. Gelatinous food, such as pig's 
feet and calves' brain, is harmless. Beef, mutton, game, 
probably veal, cheese, and the coarser fish, such as salmon, 
sturgeon, and lobster, must be forbidden. In general, salt and 
smoked meats ought to be proscribed. Ham is an excep- 
tion to this rule. Meats should not be fried, but broiled or 
boiled. 

Edema is often an early and very persistent symptom in 
chronic diffuse nephritis. Rest in bed, so long as it last, 
cannot therefore be established as a rule, as in acute nephritis. 
Gentle exercise with rest in the recumbent position from time 
to time is more likely to maintain a fair degree of health, but 
when edema is great, rest must be insisted upon. A diet from 
which common salt is excluded and purgatives facilitate the 
disappearance of dropsy with the greatest certainty. Milk 
which contains all of the ingredients needed for the mainte- 



CHRONIC DIFFUSE NEPHRITIS. 359 

nance of life, has in it a minimum amount of salt, but milk must 
be prescribed in small quantities, not more than six glasses daily 
at first. When improvement is established fruits also can be 
permitted. Later when edema is almost or quite gone, breads, 
rice and cereals prepared without salt, and custards or raw eggs 
can be added to the foods already prescribed. Such manage- 
ment often will effect the removal of dropsy. In other cases 
the fluid must be drained from the edematous tissues through 
incisions made at the ankles or through trocars inserted into 
the swollen legs. A diet free from salt or relatively so will 
help greatly to prevent its prompt reaccumulation. 

During the inclement months of the year a residence in mild 
and warm climates should be advised. A winter in Egypt, 
Florida, California, southwestern Texas, or Arizona is especially 
beneficial. The sufferer is able in these places to be out-of-doors 
and to obtain the tonic effect of fresh air and sunshine. In 
Egypt or Arizona, and to a less extent in California and Texas, 
the dryness of the air will promote rapid exhalation of moisture 
from the lungs and skin, and will tend to diminish, or at least 
to prevent rapid increase of edema. 

Daily rubbing of the skin with a woolen cloth or rough towel 
does good. If there are uremic symptoms, hot baths must be 
taken. The greatest care must be exercised to protect the 
skin against cold. 

The bowels must be well and regularly emptied in mild cases. 
More copious, even drastic, purgation may be needed in some 
instances, especially when edema exists or uremia threatens or 
exists. 

A residence at spas often does good. The change of scene, 
and of mode of living, and the greater amount of out-of-door 
life are helpful. The best waters are those that are purest and 
freest from mineral matter. For certain patients a slightly 
laxative saline water is good. As a rule, the best effect of the 
water is obtained from the quantity of it that is drunk rather 
than from mineral ingredients in it. The waters of the Wau- 
kesha Springs of Wisconsin and of the Poland Springs of 
Maine are therefore among the best because they contain so 
little mineral matter. 



360 DISEASES OF THE KIDNEYS. 

INTERSTITIAL NEPHRITIS 
Causes 

Interstitial nephritis is due either to arteriofibrosis and 
consequent destructive anemia of minute areas of renal tissue, 
or to toxins that, acting intermittently over long periods of 
time, similarly destroy minute areas of tissue successively. 
The toxins commonly may be inorganic salts, or those produc- 
ing what is called the uric acid diathesis. Generous, one 
might almost say gluttonous, eating of rich foods, especially 
beef, mutton, and game, with rich gravies, sauces, and soups, 
drinking small quantities of fluid, unless it be alcoholic bever- 
ages, and a sedentary life are the factors usually producing this 
diathesis; but in some persons of abstemious habits it may 
appear as an inheritance. Hard work, physical or mental 
and hearty eating are important causes of atheroma and 
arteriosclerotic changes, which frequently produce the local 
anemias in the kidney that cause this lesion. It is therefore 
evident that indiscretions in diet play an important part in 
producing contracted kidney. 

Treatment 

Interstitial nephritis is so chronic a disease that an exclusive 
milk diet, even if it were necessary, could be maintained only 
for a small part of its entire course. The observations of 
Zasiadko, of St. Petersburg, are suggestive of the value of 
different diets in chronic nephritis. He administered to ten 
patients suffering from chronic nephritis a vegetable diet for 
ten days; for a like period, an animal diet, with a little bread 
added; and for another equal period of time, a mixed diet. 
While upon a vegetable diet the amount of albumin in the 
urine increased, arterial tension diminished, dropsy increased, 
the pulse became slower, weaker, and softer, appetite failed, 
and the patient became weaker and more apathetic; while 
upon animal food, albumin increased in the urine, arterial 
tension rose, edema lessened, the pulse quickened and grew 
fuller, and the patients became stronger and more cheerful. 
The effects of a mixed diet were midway between these. 



INTERSTITIAL NEPHRITIS. 36 1 

The best foods for patients with contracted kidneys must be 
determined to some extent by trial in each case. Disturbances 
of digestion must also guide the physician in making a dietetic 
prescription. A mixed diet is safest except when the urine is 
much diminished by acute exacerbations of the nephritis. A 
milk diet for a time is then needed. It is also needed in the 
last stage of the illness when the heart grows weak and the pulse 
soft. In this disease uremia, in mild or severe form, frequently 
occurs, and it also is an indication for the exclusive use of milk 
or temporary abstinence from food (see Uremia). 

Under other circumstances than these the diet maybe varied 
and mixed. Food should, however, be eaten abstemiously. 
The greatest care should be taken to prevent overtaxing the 
digestive organs, or permitting an accumulation of food or of 
its detritus in the alimentary canal. An abstemious diet, such 
as can be permitted, is not natural to most who suffer from this 
disease. They are usually high livers, fond of the richest foods, 
and of generous quantities of them. It is safest for such 
patients to eschew meat soups, beef-extracts, red meats, game, 
crustaceans, and cheese. With the exception of milk, which 
should form an important element of diet, it is best for them to 
use even the simplest animal food in small quantities. In this 
disease meat foods possess the same relative toxicity as in 
diffuse nephitis. If the condition of digestion will permit, 
fats, cream, butter, and farinaceous foods should be eaten freely. 

In order to prolong, as much as possible, the life of a patient 
suffering from this disease, every care must be taken to prevent, 
or to correct, indigestion, and to maintain a copious flow of 
urine. When a mixed diet is permitted, water should be drunk 
copiously. At least two quarts of liquid should be taken 
daily. Water is the best beverage, and a water that contains 
little or no mineral matter is to be preferred. Tea , coffee, cocoa, 
or chocolate may be used in moderation, provided digestion is 
good. They must not, however, be permitted to lessen the 
amount of fluid drunk daily. Those who are most prone to 
this ailment are inclined to drink little, and what they prefer 
to drink is apt to disturb digestion or the action of the kidneys 
more or less. A cup of tea or coffee at each meal or wine or 
beer is all that they crave. Such patients must be taught to 
drink water freely. If permitting them to drink tea or coffee 



362 DISEASES OF THE KIDNEYS. 

leads them, as it often does, to take less water than they should, 
those beverages must be forbidden. 

The following will illustrate a suitable menu for a day for 
one having interstitial nephritis without digestive disorders 
or other complications: 

Breakfast. — A glass of milk or cup of coffee, a small dish of 
cereal, one egg, one slice of bread and butter, fruit. 

Lunch. — A glass of milk, a small portion of asparagus or 
peas or string beans, one or two slices of bread with butter, 
fruit, fresh or stewed. 

Dinner. — About one-half of an ordinary portion of chicken, 
one potato, a small portion of cauliflower or other green vege- 
table, lettuce or tomato salad, a slice of bread and butter, a 
small portion of pudding or ice-cream or fruit. 

The patient can be instructed generally with advantage to 
drink a glass of water on first arising in the morning and about 
10 A.M., 3 and 9 P.M. 

As a rule blood tension is high in this disease and it frequently 
causes appoplexy and hemiplegia by rupturing diseased cerebral 
arteries. The high tension can often be lowered and the safety 
of the patient thereby increased by from time to time resorting 
to purgation and a most simple and abstemious diet, such as 
a modicum of milk, six or at most eight glasses daily, and fruit. 
In a few days bread and cereals may be added and later the 
usual mixed diet may be resumed. Relief of the gastro- 
intestinal tract effected by this diet, diminution of toxins 
ordinarily generated therein, and to a less extent diminution of 
the quantity of fluid passed through the blood vessels, lowers 
arterial pressure. The ill effects of high pressure and the 
increased danger of fatal accidents from it will be lessened at 
all times by preventing constipation and much fermentation 
of food in the gastrointestinal tract. 

By all clinicians alcoholic beverages are forbidden in renal 
affections because they are renal irritants, although they vary 
in toxicity, chiefly according as the proportion of alcohol that 
they contain varies. 

A permanent residence in a genial and equable climate is 
especially desirable for those affected with chronic interstitial 
nephritis. The same care to maintain a free action of the skin 



PYELITIS. 363 

by friction and by bathing is desirable in these cases as in 
diffuse nephritis. Hot baths must be taken with caution when 
there is much atheroma of arteries. Regular daily exercise 
should be encouraged, but it should never be exhausting or 
even very fatiguing. Occasional residence at spas is of benefit. 
What has already been said of their value and applicability in 
diffuse nephritis might be repeated here. 

PYELITIS 

When pyelitis is uncomplicated by nephritis, diet must be so 
prescribed as to insure a copious elimination of urine in order 
that the pelves of the kidneys will be well washed. This is 
best accomplished by drinking milk, or water, or both, freely. 
Mild cases can be greatly helped in this way, and in a little time 
the pus, mucus, and other products of inflammation can be 
washed out. If, however, the pyelitis is severe, it will be 
mitigated, the alkaline fermentation that is so usual in the 
urine of the pelvis will be lessened, and the irritating products 
of it will be more rapidly removed. When the pelvis of a 
kidney is inflamed, there is constant danger of nephritis. A 
bland diet that will not produce renal irritants must be used. 
A milk diet is the best, but a modified milk diet — such a one 
as has already been recommended for those suffering from mild 
nephritis or threatened with it — may be used. Mild cases of 
pyelitis often recover completely if patients use a generous 
mixed diet, provided they drink water copiously — say one and 
a half or two quarts daily. For these cases sulphur waters are 
recommended because of the medicinal value of the sulphureted 
hydrogen that they contain. They are usually also mildly 
laxative, which is a distinct advantage. As in nephritis, pure 
water containing little or no mineral matter is generally to be 
preferred. 

Often, as in cystitis, a farinacious, fruit and water diet 
maintained for a few days does good. Patients must be kept 
at rest, protected from cold, and when they exist, indigestion 
and constipation must be corrected. 



CHAPTER X 
DISEASES OF THE NERVOUS SYSTEM 

Neuralgias. Migraine. Neurasthenia and Hysteria. Insomnia. 
Epilepsy. Mental Diseases. 



NEURALGIAS 

Many neuralgias are not influenced by dietetic treatment. 
Many others are due to the faulty metabolism of arthritic 
diseases, gout, rheumatism, anemia, and diabetes, to chronic 
alcoholism and indigestion, to improper and insufficient food, 
or to mental or to physical strain. Regimen and a suitably 
restricted diet are of much value in the treatment of such cases. 
For the gouty, anemic, and diabetic the diet and mode of life 
appropriate to each must be prescribed. 

In most cases of neuralgia due to faulty ways of living, a 
fresh-air life in sunshine, and gentle, regular exercise are 
essential; sometimes hydrotherapy and climatic changes are 
also needed to improve nutrition and restore the nerves to a 
normal state of health. 

If a patient is in poor flesh and persistently losing, a diet 
should be prepared that will cause a gain in weight. It should 
be generous, varied, and tempting. Fats, butter, cream, and 
oils often are required in these cases. When there is much 
indigestion, a milk diet for a week or two will frequently correct 
it, and simultaneously pain will disappear. By degrees a 
generous diet may be substituted for the restricted one. 

Sour stomach resulting from the eating of sugar, fats, rich 
gravies, sauces, or pastries is a common cause of frontal head- 
ache in many persons. These foods must be forbidden. As a 
rule, coffee, tea, and soup increase the tendency to acid fermen- 
tation in the stomach, so that they should also be forbidden. 
Alcoholic beverages too are detrimental, especially beer and 
wines. 

3 6 4 



NEURALGIAS. 365 

Intercostal neuralgias, especially such as affect chiefly or 
only the left side, are almost uniformly due to flatulent indiges- 
tion, to constipation, or to both. These conditions must be 
prevented by an appropriate diet, especial care being taken to 
prevent overloading the stomach and bowels. 

Gastralgia frequently causes a dread of eating, even when 
there is no persistent digestive disorder. Patients place them- 
selves voluntarily on an extremely restricted diet and thereby 
help to cause emaciation and great feebleness. As a rule, other 
functional nervous disorders also aid in producing malnutrition. 
In severe cases of gastralgia it is often difficult to persuade 
patients to take as much food as they should. They must be 
taught by demonstration that it is not a particular article of 
food that provokes the paroxysms of pain. A rest cure for 
the neurasthenia of which gastralgia may be a symptom is 
sometimes necessary. When nervous dyspepsia exists, at 
least a milk diet, better still the entire regimen of the ' rest cure,' 
should be prescribed. In mild cases in which the attacks are 
infrequent a prolonged restriction of diet is unnecessary. For 
a few days after an attack, little food, and that of the simplest 
kinds, should be eaten. 

There are other cases in which hearty eating precipitates an 
attack of pain when the patient is excessively fatigued or 
mentally depressed. In other individuals, idiosyncrasies as to 
foods are its immediate cause; therefore those that provoke 
gastralgia must always be avoided. When mental depression 
or physical fatigue exists, and is a predisposing cause of the 
pain, the hearty eating of even the simplest food must be 
prohibited. 

There is no one diet that is suited to all cases of gastralgia. 
It must be adapted to the especial needs of the individual case. 

MIGRAINE 

Migraine is sometimes due to eye-strain, very rarely to ade- 
noids in the pharynx or to disease of the nose. Uterine and 
menstrual disorders also may cause attacks. Heredity plays 
an important part in the production of many cases, while a 
gouty diathesis, which is often inherited, is the cause in most 



3 66 



DISEASES OF THE NERVOUS SYSTEM. 



instances. The presence of disease of the eyes, nose, pharynx, 
and uterus should always be ascertained, for it is sometimes a 
cause of migraine. Those cases that have a lithemic origin can 
be greatly helped by a suitable diet and mode of life. A gen- 
erous amount of exercise out-of-doors ought to be taken daily. 
Especially should pains be taken to practise deep breathing 
with great frequency, in order to promote better metabolism, 
first by producing as complete oxygenation of the blood as 
possible, secondly, by filling the lungs with fresh air and thereby 
eliminating waste-products from the blood, and lastly, by 
promoting good lymphatic and venous circulation in liver, 
stomach, and abdominal viscera through the suction that con- 
siderable changes of intrathoracic pressure effects. Occasional 
hot baths and frequent vigorous rubbing of the skin are 
beneficial. 

Water should be drunk freely — at least six or eight glasses 
daily. Water and milk are especially needed to help dilute the 
blood, to hold in solution waste matter and toxic substances, and 
to eliminate them by the kidneys. Alcoholic beverages should 
be forbidden. In many instances tea and coffee are also 
harmful ; in others they may be permitted if used sparingly and 
without sugar and cream. 

Cereal foods may be eaten in small quantities with a very little 
sugar, or with saccharin as a substitute; likewise custards, 
corn-starch, and blanc mange. Dry bread may also be per- 
mitted, but no hot breads, rolls, pancakes, or pastries. Fruits 
may be eaten, providing they are not too acid, as strawberries, 
currants, gooseberries, and cherries are likely to be; also stewed 
fruits if they are not too sweet. The simpler vegetables, such as 
potatoes, baked or mashed, squash, string or wax-beans, peas, 
corn, tomatoes, spinach, lettuce, asparagus, cucumbers, and 
onions, may be prescribed, but cabbage, cauliflower, baked and 
Lima beans, beets, and turnips are usually not well digested. 
Eggs, fish, oysters, the white meat of fowl, and, once in a while, 
tender lean beef or lamb may be allowed; cheese, however, and 
high game, pork, fat mutton, and rich gravies and sauces are 
likely to do harm. Moreover, patients should be taught to eat 
whatever food is permitted in small amounts. Those patients 
who pursue this regimen strictly are able to avert their headaches 



MIGRAINE. 367 

but indiscretions in eating, especially overeating, or extreme 
weariness or undue anxiety are likely to cause an occasional 
attack. The bowels should be moved freely each day. 

I believe that for those sufferers from migraine who are 
disposed to so-called uric acid troubles the most important of 
these regulations are exercise, copious drinking of water or 
milk, and the abstemious use of simple foods. 

NEURASTHENIA AND HYSTERIA 

In many cases of hysteria diet need not be prescribed. This 
is also true of some cases of neurasthenia. When either malady 
is persistent, malnutrition, a lessened or capricious appetite, and 
slow and sometimes painful digestion are noticeable symptoms. 
Extreme emaciation and feebleness are prominent in severe 
cases. 

When a physician is consulted at the onset of the disease, he 
should so guide the patient that loss of flesh and strength will 
not take place. Nothing helps so much to restore those who are 
neurasthenic to health as to place them where they are free 
from excitement or depression, and where they can regain good 
flesh and strength. It is often best to remove them from the 
care of friends and family for several weeks. The rest cure 
devised by Weir Mitchell, which is surer to restore them to 
health than any other, is used, either as recommended by him 
or in a modified form, by most physicians. Mild cases of neuras- 
thenia and those of recent origin can often be cured by travel. 
A voyage at sea for those who do not suffer much from sea- 
sickness will afford mental and physical rest, as well as diver- 
sion. Travel among strangers, in the midst of novel and in- 
teresting sights, will stimulate patients to exercise in the open 
air, will improve appetite and digestion, divert thoughts from 
business or other worry, and promote sleep. 

When the rest cure must be enforced, the patient should be 
removed from home, and no friends and relatives nor any but 
agreeable news allowed for several weeks to come to her. As she 
must be in the company of her nurse for a considerable time, one 
should be selected who will be agreeable to her. The patient 
should keep her bed for six weeks at least, leaving it only to use 



368 DISEASES OF THE NERVOUS SYSTEM. 

the vessel. It is best to begin the milk diet gradually. If a 
patient does not like milk, it should be given in doses of one or 
two ounces every two hours. Sometimes it is best to begin 
with skimmed milk, to use even smaller doses, and to permit 
the use of a little other food at meal-times. In two or three days 
larger amounts can readily be taken. As much as two quarts 
of milk ought to be drunk in twenty-four hours. In some cases 
food should be given even at night, as often as every three or 
four hours. As a rule, an exclusive milk diet quickly causes 
dyspeptic symptoms to disappear, but constipation persists or 
develops. It must be corrected by the administration of a 
mild laxative at night. A cup of coffee without sugar, in the 
morning, sometimes helps to move the bowels. Massage should 
be practised each day, usually at noon, and should be given so 
as to help in preventing constipation. At first it must be 
applied gently for only fifteen or twenty minutes, the abdomen 
being rubbed carefully, especially along the course of the colon. 
By degrees a longer time, and ultimately an hour a day, may 
be devoted to massage. A hot sponge bath may be given in the 
early morning and the clothing of the patient be changed. 

At the end of ten days an egg or a chop should be eaten at 
noon, in addition to the usual allowance of milk. Weir Mitchell 
often prescribes earlier than this meat-juice once or twice in the 
day. In another day or two, bread and butter are given, and an 
egg or some meat at breakfast as well as at dinner. Some sim- 
ple vegetable and stewed fruit may soon be added to the diet. 
By degrees the patient is thus gotten upon a diet of three simple 
but generous meals daily, besides three of four pints of milk. 
The latter is administered partly with the meals and partly 
between them. 

While the patient is upon milk only, she is not permitted 
even to sit up in bed. But when three meals a day are taken, 
she may sit up while eating. At first solid foods are cut fine, 
and at all times they must be eaten slowly and well masticated 
before swallowing. Weir Mitchell recommends the generous 
use of butter, and in those cases in which flesh is not rapidly 
gained, the administration of cod-liver oil. If swallowing the 
oil lessens appetite or creates nausea an emulsion may be in- 
jected by the rectum. 



NEURASTHENIA AND HYSTERIA. 369 

When patients first are permitted to sit up, it is for a short 
time only. By degrees they are allowed to be up more hours 
in the day, but for some time after their morning bath, and 
again after massage, they ought to rest. 

During treatment the stools should be watched. If food is 
voided undigested, the amount should be lessened. A urine 
loaded with urates also indicates overfeeding. 

When, at the end of eight or ten weeks, the patient is per- 
mitted to return home, her gain in flesh, in color, in vigor, and 
mental poise is so great that convalescence appears fully 
established, yet recovery is not complete. The diet should still 
continue to be generous and simple; excitement should be 
avoided, and outdoor exercise encouraged. 

Patients requiring this treatment easily become addicted to 
the use of alcoholic beverages, wherefore it is often desirable to 
forbid them entirely. When this is not necessary, some 
physicians permit their moderate employment. As they are 
not necessary, it is usually safer not to employ them at all. 

Electricity — the faradaic current — is occasionally used to 
supplement massage. Also iron and strychnin, as well as 
tonic laxatives, like aloes and cascara sagrada, are often needed. 

The following synopsis of the management of an individual 
case of Weir Mitchell's is appended to illustrate the practical 
application of the rest cure : 

Mrs. C, kept in bed, fed by an attendant, rose only to relieve bladder 
and rectum. 

First day: One quart of milk in divided doses every three hours. 

Second day: Cup of coffee on awakening. Two quarts of milk in 
divided doses every two hours. Aloetic pill at night. 

Third to sixth day : Same diet. 

Seventh, eighth, and ninth days: Same diet, with a pint of raw soup 1 
in three portions. 

Tenth day: 7 a. m., coffee. 7.30 a. m., half a pint of milk. 10 a. m., 
12 noon, 2, 4, 6, 8, and 10 p. m., ditto. Soup at 11 a. m., 5, and 9 p. If. 

1 This is made by chopping up one pound of raw beef and placing it in a bottle with 
a pint of water and five drops of strong hydrochloric acid. The mixture stands in ice all 
night; in the morning the bottle is put into a pan of water at 1 10° F.. and kept two hours 
at about that temperature. The mixture is then thrown into a stout cloth and strained 
until the mass that remains is nearly dry. If the raw taste proves very objectionable, the 
beef to be used is first quickly broiled on one side and then the process is completed in the 
manner previously described. 

24 



370 DISEASES OF THE NERVOUS SYSTEM. 

Fourteenth day: Eggs, and bread and butter added. 

Sixteenth day: Dinner added and iron. 

Nineteenth day: The entire diet was as follows: 7 a. m., coffee. 8 
a. m., iron and malt extract; breakfast, consisting of a chop, bread and 
butter, a tumbler and a half of milk. 11 a. m., soup. 2 p. m., iron and 
malt; dinner of anything liked, with six ounces of Burgundy or dry 
champagne, and at end one or two tumblers of milk. 4 p. m., soup. 
7 p. m., malt, iron, bread and butter, usually some fruit, and two glasses 
of milk. 9 p. m., soup. 10 p. m., aloetic pill. 

At 12 noon, massage for an hour. At 4.30 p. m., electricity applied 
for an hour. 

Sixth week: Soup and wine were dropped, iron lessened one-half; 
massage and electricity only on alternate days; 1/30 of a grain of 
strychnin sulphate thrice a day at meals given (continued for several 
months) . 

Ninth week: Milk reduced to a quart. All mechanical treatment 
ceased. 

Result: Gain in flesh about face in second week. Weight rose in 
two months from 96 to 136 pounds; gain in color equally marked. On 
thirtieth day patient had normal catamenial flow, after five years of 
failure to menstruate. Ninth week, drove out. Cure complete and 
permanent. 

INSOMNIA 

Causes 

There are cases of sleeplessness that do not require dietetic 
treatment ; there are others that can be cured by it ; and some 
in which it is an important aid to medicinal treatment. 

During sleep glandular functions are less active than during 
waking hours. The strong and active do not become drowsy 
after meals. Indeed, sleep is usually not sound and is sometimes 
impossible until digestion is partly completed. In general it 
may be said that at least from two and one-half to three hours 
should elapse between supper and bedtime. When the stomach 
is full and digestion is most active, sleep cannot be had or is 
much disturbed. The same thing is true when digestion is very 
slow or the evening meal has been a heavy one, even if two or 
three hours elapse between supper and bedtime. An exception 
to this general statement is found in the aged and the feeble, who 
often feel drowsy after meals. They may doze immediately 
after eating, but they rarely sleep soundly. The sudden need 



INSOMNIA. 371 

of much blood in the abdominal viscera to promote digestion 
depletes the cerebral vessels and disposes them to sleep. 

In some cases sleep occurs during the first two or three hours 
after retiring and is then followed by wakefulness. Often this 
is due to slow digestion, active churning movements not de- 
veloping until several hours after eating. In these cases also 
acid or other fermentation occurs the product of which cause 
gastric or intestinal unrest or distention but not necessarily 
pain. Frequently discomfort is so slight that it is unnoticed 
unless the patient's attention is directed to the observation 
of feelings in the abdomen during the hours of wakefulness. 

Insomnia is very persistent and troublesome when a good 
state of nutrition is not maintained. Malnutrition and an 
excitable nervous system make many neurasthenics sleepless. 

Treatment 

When, in a person who is well nourished, sleep is disturbed 
and brief, and digestion is slow or poor, it is best to leave a con- 
siderable interval between the last hearty meal of the day and 
bedtime. The hearty meal should come at noon or at least not 
later than five in the afternoon. In the evening a light meal may 
be eaten — a sandwich with fruit, or a glass of milk, or bread and 
milk, or other simple foods in small amounts. In such cases all 
the meals should be of very moderate size and simple. Both 
by adjustment of diet and by exercise and relaxaton the diges- 
tive disorder should be corrected. 

Late and very large meals must be avoided by those who are 
inclined to be sleepless, for gastric distention, whether by food 
and drink, or by gases resulting from indigestion, often causes 
sleeplessness. Frequently sour stomach also will interfere with 
sound or prolonged sleep. As the drinking of wine and beer, 
as well as the eating of rich food, is likely to cause this condition, 
the necessity of forbidding alcohol and rich food to such patients 
is self-evident. 

Neurasthenics often obtain relief from the forced feeding of 
the rest cure. In mild cases a glass of warm milk or a cup of 
warm bouillon and a few crackers at bedtime promote drowsi- 
ness and, being quickly digested, will not disturb sleep. When 
there are great inanition and sleeplessness, food should be of the 



37 2 DISEASES OF THE NERVOUS SYSTEM. 

simplest kind and given often, so as to promote strength and 
increase flesh. A milk diet, supplemented gradually by a 
variety of nutritious and easily digested foods, is usually the 
best. 

Many persons cannot drink tea and coffee at night without 
having sleep prevented or broken. This is so generally true 
that their use at night must be forbidden. Tobacco acts in the 
same way occasionally, but much less frequently than do tea 
and coffee. 

Relief from business or other worry, and diversion from 
mental work or preoccupying cares, are as essential to the 
successful cure of insomnia as dietetic changes. Travel, a 
change of occupation, in mild cases games and reading at night, 
the lightest kind of unexciting literature, will often afford the 
needed diversion. Regular habits, regular times for work, for 
relaxation, and for sleep are necessary to prevent insomnia in 
certain persons. 

EPILEPSY 

There is no one diet that is indicated in epilepsy ; yet patients 
having this disease are greatly helped or harmed by judicious or 
indiscreet eating. Indigestion or slow and labored digestion, a 
distended stomach, or an overloaded colon, are common causes 
of attacks. The epileptic should be abstemious. Unfortu- 
nately, the natural tendency of most patients is to overeat. In- 
digestion should at once be corrected by appropriate treatment, 
and constipation prevented or relieved. The character of in- 
digestion, the existence of gastric or intestinal indigestion, 
together with other conditions, will govern the diet that is 
appropriate to individual cases. All epileptics should be 
taught the relationship between digestive disorders or con- 
stipation and their ailment, and the necessity of eating ab- 
stemiously and of maintaining regular and full daily bowel 
movements. 

Sweets ought to be avoided by epileptics. It is also generally 
believed that meats should be used very sparingly. They are 
usually prescribed to be eaten not oftener than once daily, and 
then in small amounts. Great benefit has been observed in 



EPILEPSY. 373 

most cases from the restriction of this article of diet. Gowers, 
however, describes a case in which paroxysms were always 
aggravated by a vegetarian diet and relieved by the moderate 
use of meat. It is evident, therefore, that no one diet is appli- 
cable to all cases, the most important thing being the restriction 
of the amount of food eaten and the limitation of the variety 
of food to those articles that are easiest to digest and to absorb. 

During the last few years, many physicians have found a salt- 
free diet of great benefit in preventing epilepsy or in lengthen- 
ing the intervals between attacks. Milk and fruits contain a 
minimum amount of sodium chloride but almost all other 
classes of foods can be permitted in moderate amounts provided 
they are cooked without salt. It is difficult to keep a patient 
long upon such a diet. Therefore it must be used intermittently 
rather than steadily. It is possible that the relatively large 
amount of salt in meat and ordinarily cooked with it makes it 
unadapted to use by epileptics rather than its protein content 
or extractives. 

The following is a sample menu for a day of the epileptic 
colony at Chelfont St. Peter: Breakfast, oatmeal porridge with 
new milk, tea, and bread and butter: Dinner, roast or boiled or 
hashed beef, mutton, or fish, cabbages and potatoes, followed 
by rice, sago, tapioca, suet, or jam-roll, pudding, tea with bread 
and butter or dripping or sometimes golden syrup or currant 
cake: Supper, some pudding, generally with milk and bread, 
varied occasionally with soup. The following are sample 
menus of the State Hospital for Epileptics at Gallipolis, Ohio : 

Sunday: 

Breakfast: Oatmeal and milk; potatoes in stew (3 ounces); apple 
stew (7 ounces) — green apples; bread; butter (1/2 ounce); 
coffee (1/2 ounce); milk. 
Dinner: Vegetable soup; stewed chicken or roast veal (4 ounces); 
mashed potatoes; stewed tomatoes (5 ounces): rice pudding; 
bread; butter (£ ounce); milk. 
Supper: Corn-starch pudding (1/2 ounce corn-starch; raisins, 1/10 
ounce) ; fruit, canned or fresh; cookies or cinnamon cake; bread ; 
butter (1/2 ounce); milk. 
Monday: 

Breakfast: Cracked wheat; boiled or steamed potatoes in jackets 
(4 ounces); prunes; bread; butter (1/2 ounce); milk. 



374 DISEASES OF THE NERVOUS SYSTEM. 

Dinner: Beef soup (beef bones, 3 ounces); roast beef (6 ounces) ; 

bread dressing and gravy; boiled onions (4 ounces); steamed 

potatoes, pared (6 ounces); bread; butter (1/2 ounce); blanc 

mange; corn bread; milk. 
Supper: Mush and milk; evaporated peaches (1 ounce); bread; 

butter (1/2 ounce); milk. 
Tuesday: 

Breakfast: Rolled oats; stewed prunes (1 3/4 ounces); butter (1/2 

ounce); coffee (1/2 ounce); milk. 
Dinner: Vegetable soup; roast mutton (6 ounces) ; mashed potatoes 

(6 ounces); parsnips, boiled (6 ounces); cucumber pickles; 

bread; butter (1/2 ounce); bread pudding; milk. 
Supper: Baked potatoes (5 ounces); apple-sauce (7 ounces) — green 

apples; ginger bread; bread; butter (1/2 ounce); milk. 
Wednesday: 

Breakfast: Hominy (2/3 ounce) or rolled oats (3/4 ounce); bread; 

butter (1/2 ounce); milk toast; peaches; coffee (1/2 ounce); 

milk. 
Dinner: Bean soup; roast beef; stewed corn; boiled potatoes, pared 

(6 ounces), or boiled turnips (8 ounces); rice pudding; bread; 

butter (1/2 ounce); milk. 
Supper: Mush and milk; evaporated apricots (1 ounce) or rhubarb 

sauce (4 ounces); bread; pickles; butter (1/2 ounce); milk. 
Thursday: 

Breakfast: Oatmeal; prunes; bread; butter (1/2 ounce); coffee (1/2 

ounce) ; milk. 
Dinner: Beef soup; boiled beef; boiled cabbage (8 ounces); boiled 

potatoes in jackets (4 ounces); bread; butter (1/2 ounce); 

milk; bread pudding. 
Supper: Fruit (4 ounces); rice; butter (1/2 ounce); milk; bread. 
Friday: 

Breakfast : Steamed potatoes, pared (6 ounces) ; fruit, evaporated 

or fresh; bread; butter (1/2 ounce); coffee (1/2 ounce); milk. 
Dinner: Oyster soup or vegetable soup; fresh fish; succotash (lima 

beans 1 ounce and canned corn 3 ounces); boiled potatoes, 

pared (6 ounces), or vegetable oysters (6 ounces); corn -starch 

pudding; bread; butter (1/2 ounce); milk. 
Supper: Fruit (4 ounces); rice; butter (1/2 ounce); milk; bread. 
Saturday: 

Breakfast: Potatoes (4 ounces) or hominy (2/3 ounce); bread; 

peaches; butter (1/2 ounce); coffee (1/2 ounce); milk; bread. 
Dinner: Beef soup; boiled beef, corned or fresh (6 ounces); sauer- 

krout (6 ounces) ; boiled potatoes, pared (6 ounces) , or boiled 

beans (1 1/2 ounces); bread; butter (1/2 ounce); milk; rice 

pudding. 
Supper: Mush and milk; fruit (4 ounces) ; bread; butter (1/2 ounce) ; 

milk. 



MENTAL DISEASES. 375 

Fresh vegetables, fruits, especially prunes, figs, apples, dates, 
oranges, etc., are needed to maintain regular bowel movements. 

In early childhood, epilepsy is commonly associated with a 
rachitic condition. A proper diet will accomplish more for the 
relief of this ailment in childhood than in adult life. 

MENTAL DISEASES 

In such mental diseases as acute insanity, melancholia, de- 
mentia, and mania, food is frequently refused, and consequently 
emaciation and great feebleness follow. Food is refused for 
various reasons. In dementia, paresis may render swallowing 
difficult. In other cases chronic gastritis causes distress after 
eating, which is exaggerated by the patient and made a pretext 
for refusing food. A few patients are afraid of poisons, but 
will sometimes eat if they see the raw food prepared. Others 
will not eat food prepared in certain ways, or will not take food 
from certain individuals. These and many other peculiarities 
necessitate a careful study of each patient and an adaptation of 
food or methods of service to the individual. Occasionally a 
patient is seen who will eat if his attention can be fastened on 
the food for a sufficient length of time. 

However, in spite of various attempts to induce these patients 
to eat, food must at times be forced upon them. Forced feeding 
is accomplished by administering liquid nourishment through an 
esophageal or nasal tube. The discomfort attending this pro- 
cedure, which is looked upon by some clinicians as a discipline of 
value, will induce the most reasonable ones to eat. 

If patients become very violent when the attempt is made to 
force food upon them, they must be held by assistants until a 
gag can be placed between the teeth, and the tube inserted. 
The whole process of feeding does not require more than four or 
five minutes when carried out skilfully. 

The nasal tube can be used without applying a gag and is 
therefore preferred by many. There is, however, danger of 
introducing it into the trachea instead of into the esophagus. 
Moreover, there is greater danger of regurgitation alongside of the 
small tube than alongside of the larger one. On the other hand, 
a gag has been known to break the teeth of violent patients 



376 DISEASES OF THE NERVOUS SYSTEM. 

and usually hurts the mouth. Still, the stomach-tube is the 
best to use, because of the greater certainty of passing it into the 
esophagus. 

The patient should be sitting or reclining when the tube is 
passed; his legs and arms being firmly held by assistants. 
When the mouth is forced open and the gag is placed, the 
patient's head must be steadied by a nurse and the tube must 
be pushed rapidly into the stomach. If the patient suffers 
from gastritis, it may be necessary to wash the stomach before 
food is introduced; but usually this need not be done. A 
quart of warm milk with slightly cooked or raw eggs, or a little 
oatmeal jelly, barley, Mellin's food, malted milk, or similar liquid 
nourishment added, should be poured into the stomach. In- 
stead of milk, meat-juice, broths thickened with rice, or puree 
of potato or peas, may be used. When starches are employed, 
it is best to add one or two tablespoonfuls of a malt extract, 
which possesses diastatic power, or taka-diastase, as food given 
to a patient in this way is not mixed with his own saliva and 
digested by it. Patients who are in good health may not need 
to be fed more than twice daily; but those who are weak or 
losing flesh rapidly should be fed three or four times. 

Many feeble patients improve in their mental state as they 
gain in flesh. When such results can be hoped for, patients 
should be given as large an amount of food as their digestive 
organs will dispose of. 

Those who suffer from mental disease must be watched while 
eating. Attention must be paid to the size of the mouthfuls 
that they take. Many will bolt large pieces of food that cannot 
be easily digested, and may excite persistent indigestion. 
Patients occasionally choke themselves in this way. Death 
results, too, from the lodgment of food in the larynx. For 
such patients food must be finely divided or liquid. They 
must not be permitted to wash down with water or other 
beverage, food that has been imperfectly chewed. 

For those who suffer from mental disorders the problem is 
therefore rather one of feeding, than of the character of the food. 



CHAPTER XI 
DISEASES OF THE SKIN 

Eczema. Acne Rosacea. Acne. Furunculosis. Urticaria. 

ECZEMA 

Eczema is undoubtedly a disease excited by local irritation. 
It is most easily excited and most likely to be prolonged and 
severe when metabolism is disturbed. Eating and foods there- 
fore play a part in causing and in prolonging the disease. It 
occurs frequently as a complication of diabetes, of a gouty or 
strumous tendency, and of Bright's disease. Dietetic treatment 
appropriate to these disorders is an important aid in the manage- 
ment of eczema. 

Whatever the condition of the patient may be as regards 
flesh, the diet should be so adjusted as to prevent digestive 
disorders, and to avoid overworking the liver or surcharging 
the blood with effete matter. Food should, as a rule, be taken 
in moderate quantities. 

"When eczema occurs, as it often does, in those who are stout, 
the diet should be simplified and flesh reduced. A milk diet 
for a few days, with gentle purgation, will help to make the 
gastrointestinal canal cleaner, will stimulate diuresis, and 
thus wash from the blood unwholesome ingredients. Even 
when two quarts are consumed in twenty-four hours, less 
nourishment will be taken than is habitual. Such a diet main- 
tained for a few days and subsequently gradually modified, 
will lead to a diminution of flesh and to healthier metabolism. 
Fruits, the simple vegetables, breads, fish, and eggs, may be 
used after the first few days, and the quantity of milk lessened. 
Red meats should be forbidden for a time and later used 
sparingly. 

L. D. Bulkley recommends in acute generalized eczema and 

377 



378 DISEASES OF THE SKIN. 

other acute inflammations of the skin a diet of rice, bread and 
butter and water for from three to five days, during which time 
usually the acute symptoms subside or disappear. The quant- 
ity of food eaten by a patient upon such a diet is necessarily 
small. It will produce calories but will not tax the liver and 
kidneys. 

Stout infants who suffer from eczema are sometimes bene- 
fited by simplifying the diet of the nurse. In bottle-fed 
babies too much farinaceous food and too much sugar are often 
harmful. The diet of the mother must be studied and pre- 
scribed carefully if she suckles the babe, and if she feeds it from 
a bottle, care must be taken to adapt the food to the child's 
power to digest and assimilate. 

Too little food, because of poverty, and lack of cleanliness 
are also causes of eczema. Many patients of this class are 
strumous as well. Sufficient food, well cooked, quickly causes 
stubborn eczema to disappear in such cases, in which cream, 
butter, olive oil, and cod-liver oil may also be given with great 
advantage. Every attempt should be made to improve 
nutrition. 

In other cases it is necessary to forbid rich foods, fried food, 
especially sweet food and all other kinds tending to produce 
indigestion. The vegetables that are least digestible, such as 
cabbage, turnip, sweet potato, and egg plant, must be forbidden; 
occasionally, also, oatmeal, bananas, peaches, pears, and straw- 
berries, and usually pork, ' high ' game, salt and smoked meats. 
In certain cases dyspepsias must be cured and a diet that over- 
loads the urine with phosphates, urates, and oxalates must be 
corrected. 

ACNE ROSACEA 

• While this disease is undoubtedly due in many instances to 
the persistent use of alcohol, yet bad cases are often observable 
in total abstainers. The abuse of alcohol is, therefore, not its 
only cause. Digestive and uterine derangements also act as 
provocatives. When once established, the trouble will be 
aggravated by exposure to cold and to excitement, while 
constipation and indigestion, especially when chronic, will 



ACNE. 



379 



increase its severity and persistency. In women, uterine 
disorders are an extremely common cause of it and should 
always be sought for and corrected. Alcoholic beverages 
should be forbidden in all cases. 

No one diet can be prescribed. Food must be carefully 
adapted to the digestive disorder that may afflict the patient. 
Distention of stomach and bowels from overeating, by fermen- 
tation, and because of chronic constipation must especially be 
prevented. No restriction of diet is so important to insure 
relief as eating abstemiously and avoiding meats and rich food. 

The disease is a chronic one, sure to tax the patience and 
ingenuity of the physician. Local treatment is quite as neces- 
sary as dietetic and hygienic measures. 

ACNE 

Derangement of the digestive, or of the sexual organs, pre- 
disposes to outbreaks of acne. The disease is so chronic and 
intractable that it invariably tries the patience and skill of a 
physician. Nothing contributes more certainly to its relief 
than preventing abnormal fermentation in the gastrointestinal 
tract. This can be accomplished best by a diet of simply 
prepared foods, by their abstemious use, and by frequent, some- 
times daily, gentle purgings. A dose of Carlsbad salts in a 
glass of water taken when the patient first arises will usually 
suffice as a purge. A glass of hot water twenty or thirty 
minutes before meals is a help. Overeating, which is especially 
apt to be indulged in at puberty when children grow rapidly, 
must be forbidden. The trouble is produced or aggravated in 
many cases by oatmeal, pancakes, particularly when made of 
buckwheat, pastries, candies, and sweets generally. To the 
list of foods that must be forbidden, or whose use must be regu- 
lated carefully, should be added foods cooked in fat, such as fried 
meats and vegetables, sausages, doughnuts, cheese, and any 
other food slow to digest or liable to ferment. Coffee and tea 
made very sweet are also often harmful. 

When derangements of the sexual organs exist, they must be 
corrected. The period of puberty is often accompanied with 
persistent or recurrent acne, and while treatment may diminish 



380 DISEASES OF THE SKIN. 

the disfigurement, time alone seems able to bring complete 
relief. 

The affected portions of the skin must be kept clean and 
functionally active. Fomentations and massage help to do 
this. Antiseptics may also usefully be applied. 

FURUNCULOSIS 

The same dietetic regimen that has been recommended for 
acne is useful in furunculosis. The key to it is abstemiousness 
in eating and the use of simply prepared foods. In both dis- 
eases, water should be taken freely between and before meals. 

A change of climate is of great help, as are also hot baths, 
especially when taken at a spa. Both stimulate improvement 
in nutrition. The baths produce freer action of the skin, keep 
it clean, and act soothingly upon the areas of inflammation in it. 

URTICARIA 

This skin eruption more than any other is due to dietetic 
faults or to idiosyncrasies. Certain foods provoke an urticaria 
in those who are liable to it, as certainly as iodids and bromids 
produce acne in others. It is not necessary for its production 
that the food be stale or spoiled. The cleanest or freshest 
fruit or shell-fish may cause it. Whether the eruption is due 
to an attempt to eliminate through the skin certain substances 
introduced into the blood from the offending food, or is pro- 
voked by irritation of the unduly sensitive vasonervous mech- 
anism, is not certain. Overloading the stomach will also cause 
it in many cases. Those who are inclined to gout, frequently 
suffer from urticaria when they indulge in too much nitrogenous 
food. 

Idiosyncrasy marks the causal relationship of foods to this 
disease. One article after another must be forbidden until the 
toxic one is found. Shell-fish, crustaceans, and strawberries are 
most likely to provoke attacks. Not infrequently a patient 
will be found who cannot eat buckwheat cakes without attacks 
of urticaria. Occasionally fish, pork, and eggs will excite it. 
To so great an extent is the relationship of food to the disease a 



URTICARIA. 381 

peculiarity of each patient that no general diet can be 
prescribed. 

One of the most persistent cases under my care occurred in 
a medical student. After repeatedly advising the discontinu- 
ance of first one article of food and then another, he told me that 
for economy he had been living on milk alone and had been 
drinking large quantities of it. As soon as the quantity of 
milk was diminished and his diet was varied more the urticaria 
disappeared. 

In chronic cases it is difficult to discover the cause of the 
disorder. It must not be forgotten that uterine derangements 
will start outbreaks in some women. 



CHAPTER XII 

DISORDERS OF NUTRITION 

Emaciation. Obesity. Rachitis. Osteomalacia. Scurvy. Beri- 
beri. Diabetes. Rheumatoid Arthritis. Gout and Goutiness. 

EMACIATION 

Causes 

Emaciation is a relative term, for there are families who are 
habitually thin. Members of such families may be strong and 
vigorous, although noticeably spare. In these cases leanness 
is an inherited condition. In other instances it may be due 
to insufficiency of food, poor cooking, or bad quality of food, or 
to imperfect mastication and indigestion. In most cases of 
emaciation a strong nervous element, often a genuine state of 
neurasthenia or hysteria, is a causative factor. When children 
grow tall rapidly, they are often very thin; as likewise are, in 
general, children who are nervous and extremely active. Both 
excessive nervous or muscular waste and slow or, imperfect 
assimilation are important causes of emaciation. In old age a loss 
of flesh is commonly observed. It is sometimes excessive, produc- 
ing emaciation. In such cases several factors usually contribute 
to produce the result : mastication is imperfect, appetite is poor, 
digestion is not uniformly good, assimilation is defective, and 
usually the lesion of generalized arteriosclerosis interferes 
mechanically with a good supply of nourishment to the tissues. 
Diseases, especially chronic ones, of the digestive organs also 
lead to excessive thinness. Many structural diseases of the 
brain and cord likewise cause muscular atrophy. Diabetes, 
tuberculosis, cancer, and acute and chronic fevers are equally 
common causes of loss of flesh. Each requires its appropriate 
treatment. It need not be said that in all cases of emaciation 
the cause must be removed if possible. When the condition 

382 



EMACIATION. 383 

is inherited, but little can be accomplished to relieve it. All 
nervous waste must be prevented, sleeplessness, intellectual 
excitement, worry, and excess of venery must be prevented or 
obviated. It is rare that muscular waste from work alone 
causes emaciation, but excessive physical work as well as ex- 
cessive mental work must be avoided. In many cases rest in bed 
for days or weaks must be enjoined in order to obtain such 
mental and physical repose as is necessary. Weir Mitchell's 
treatment, which has already been described as applicable to 
cases of neurasthenia, is of great service in treating many cases 
of morbid thinness. By this method prolonged mental and 
physical rest is obtained, and simultaneously an excess of 
easily digested food is given to the patient. Assimilation is 
aided by massage. In stubborn cases, more can be accom- 
plished by such treatment than by any other. 

Treatment 

Emaciation that is due to a specific disease demands the 
removal of its cause rather than treatment for itself. 

When digestion is good, an excess of food should be given, 
but not enough to provoke indigestion. Frequent meals of 
moderate size are surest to be well tolerated. It is generally 
best to first increase the protein foods for they are easiest to 
digest; then the fats and carbohydrates. Eggs are particu- 
larly useful for they are capable of adding much weight without 
taxing digestion, especially if eaten raw or soft cooked. From 
three to six daily can often be taken advantageously. Car- 
bohydrates should be given in increased amount but care must 
be taken not to overtax the digestive organs and create dyspep- 
sias. The starches and sugars are especially fattening. Oils 
and fats are also useful, but, with few exceptions, they quickly 
produce a feeling of satiety that prevents the consumption oi 
considerable quantities of food. Butter is an exception to this 
rule, and cream may be used freely upon cereals and fruits. 
Olive oil may also be used freely upon salads. A little crisp 
fried bacon is appetizing and wholesome to most persons. Even 
cold boiled ham when it is well covered with fat is digestible. 
Such articles of food should be recommended for those who 
are emaciated, but they should be prescribed in moderate 



384 DISORDERS OF NUTRITION. 

amounts only. Food should be given finely divided. In all 
cases attention should be directed to the need of complete 
mastication of all solids that are eaten. 

The following may be regarded as a typical menu for a day : 
Breakfast : One or two glasses of milk; if possible, two dishes of 
a cereal food, such as oatmeal, cracked wheat, or soft-boiled 
rice, with as much sugar and cream as the individual will 
tolerate, eggs and bacon, stewed fruit, and bread. Dinner: 
Two glasses of milk, a small portion of chicken or roast, mashed 
or baked potato, puree of other vegetables, such as peas, a 
salad with oil dressing, a farinaceous pudding, preferably one 
that can be eaten with sugar or syrup, and bread. Supper: 
Two glasses of milk, bread or cream toast, or pancakes or 
waffles with syrup, cold boiled ham, stewed fruit, or baked ap- 
ples with cream. 

Butter should be used freely on bread. If in individual 
cases it seems best, tea and coffee may be taken at meal-time, 
and milk with bread, crackers, or fruit may be taken between 
meals and at bedtime. 

Sweet beverages are useful, and syrup is an agreeable con- 
diment for emaciated patients. Like fats, it is apt to create 
a feeling of satiety if taken too freely. Beer, stout, and 
especially the sweetest malted beverages are prescribed, both 
because they are appetizing and because they contain a per- 
centage of sugar that is easily absorbed. The small per- 
centage of alcohol that they contain also helps to make tissue 
oxidation slower and fat to accumulate in the body. Sweet 
wine is prescribed for the same reasons. The amount of fat- 
producing matter, however, is much greater, measure for 
measure, in rich milk than in these beverages. In order to 
obtain good results, the need of freedom from mental or emo- 
tional excitement must be remembered. 

OBESITY 

Definition and Effects 

It is impossible to draw a line between stoutness and obesity. 
The latter word is applied to all grades of stoutness in which 
the normal, healthful action of organs is interfered with by 



OBESITY. 385 

deposits of fat. In health, fat is deposited in connective tissue. 
In the obese, this deposition becomes excessive, so that even 
the thinnest strips of connective tissue are loaded with it. 
Often fat-cells are crowded in among muscle-fibers, where they 
interfere with the active contraction of the muscle and may 
finally cause its atrophy. The viscera are also frequently en- 
veloped in masses of fat. The increased load that an obese person 
has to carry interferes with his activity and vigor of movements, 
but the fatty infiltration of muscles does so even more . The heart 
is frequently weakened to a serious extent by infiltration with fat 
or by fat enveloping it. Respiration also is made shallow and 
imperfect by the fat about the chest and the weight of the abdo- 
men. Excess in weight greatly lessens one's chances of lon- 
gevity. So great is this that life insurance companies refuse 
most applicants who are overweight. 

Causes 

Fat is derived from fat eaten, from carbohydrates, and from 
proteins, but it is produced most abundantly from the first and 
second groups of food. Each of these foods, however, is 
chemically broken up and refashioned by the human organism 
to make the fat of living tissue. Even the fat that is absorbed 
directly from the intestines must be made over to fit it to the 
human organism. 

For the production of obesity a predisposition, and generally 
an inherited one, is necessary. Obesity may develop at any 
age, but it is rare in infancy and seldom as great in advanced 
life as in middle life'. It usually develops and is greatest 
between the thirtieth and the fifty-fifth year. A tendency to 
obesity is often inherited. Numerous statistics show that 
one-half of all obese persons inherit such a tendency. Two- 
thirds of the excessively stout people are women. 

Obesity is frequently caused by eating too much. The habit 
of eating excessively is often acquired during the years of 
growth, when large amounts of food are needed both to repair 
loss and to provide material for growth. This habit is main- 
tained long aftevthe necessity for generous meals has passed. 
However, the obese do not always eat excessively. Bouchard 
found in 50 per cent, of such patients that the amount of food 

25 



386 DISORDERS OF NUTRITION. 

eaten was quite normal and its character well adapted to the 
needs of the individuals. In 40 per cent, the amount was 
excessive, and in 10 per cent, it was less than normal. 

Too little exercise plays an important part in producing 
obesity. It was a feature of 38 per cent, of Bouchard's cases. 
But in 28 per cent, an excess of exercise was taken. 

All observers admit that the habitual use of alcoholic bever- 
ages increases any natural tendency to obesity that may exist. 
This increase is effected by interfering with complete metabo- 
lism and by producing an inclination to fatty degeneration. 
While all alcoholic beverages produce these results, beer, ale and 
sweet wines are especially apt to do so. 

The chief known causes of obesity can be summarized as an 
inherited predisposition, overeating, too little exercise, and too 
much alcohol. In individual cases any one or several of these 
conditions may be wanting. 

Obesity is not infrequently associated with gout, lithemia, and 
diabetes. 

Treatment 

The treatment of obesity is not always satisfactory. While 
it is possible to reduce an individual's weight by some pounds, 
it is often extremely difficult to prevent renewed taking on of 
flesh without great discomfort. When, however, there is not 
an inherited disposition to obesity, the patient has it in his 
power to maintain a normal weight with comfort by eating 
abstemiously and taking sufficient exercise. 

The indications for treatment are : (1) To diminish the food- 
supply and to modify its character; (2) to increase the rapidity 
of tissue destruction by exercise ; (3) to affect general vitality. 

All plans of treatment are directed toward meeting the first 
indication. It is best accomplished by greatly lessening the 
amount of food eaten. The quantity consumed must be less 
than the average man will take when in health. For instance, 
it is estimated that under normal conditions a man needs in a 
day food that will produce from 2500 to 3500 calories. Banting 
advocated a diet that would furnish only 1 1 1 2 ; Oertel, one that 
would produce 1200; Ebstein, one that would produce 1400. 
These are starvation diets. I do not mean diets that will 



OBESITY. 387 

cause loss of life, but that provide less than the amount of 
nourishment needed to maintain health and strength. Many 
obese patients eat so large an amount of food that it is not 
sufficient to tell them to reduce the quantity of food they take 
from one-quarter to about one-half, for these directions may 
not reduce it even to a normal point, much less below normal. 
It is necessary to inquire particularly in each case as to the 
character of food taken and the quantity. Oftentimes a 
reduction in quantity will effect as marked a reduction in weight 
as is desired, without very much change in the character of the 
food. The disagreeable sensations arising when one is deprived 
of quantities of food to which he is accustomed are felt less if the 
change in diet is made gradually. There are many who find it 
extremely difficult to lessen the amount eaten so long as they 
are permitted to eat food that they especially like and usually 
take. For such persons a diet should be prescribed that will 
involve the withdrawal of foods that they have especially en- 
joyed and the substitution for them of kinds that they have not 
learned to relish and of which they will not be tempted to par- 
take very generously. Ebstein recommends the use of an ex- 
cess of fats because they quickly produce satiety, and therefore 
a smaller quantity of food is eaten. On the other hand, Banting, 
Oertel, Dujardin-Beaumetz, and other clinicians who have 
written upon diet for the obese diminish the quantity of fat 
that these patients eat. But all agree that the carbohydrates 
must be very much reduced. Ebstein prescribes 50 grams a 
day; Banting, 80; Oertel, from 70 to 100; and Dujardin- 
Beaumetz, 95 grams. The last-named also reduces the 
albuminoids below the average — to 55 or 60 grams; Ebstein 
recommends 100 grams; Banting and Oertel give an excess — the 
former 170 grams, the latter from 150 to 180. 

Water should not be drunk at meal-times, as with it a larger 
quantity of food can be eaten than without it and the food is 
more perfectly absorbed and assimilated. But between 
meals patients should drink at least from 1200 to 1500 c.c. 
(40 to 45 ounces) daily, gouty individuals requiring even more 
than this amount. A small cup of tea or coffee may be taken 
with the meals, but it should not be sweetened with sugar, 
although saccharin may be used instead. Skimmed milk may 
also be taken in moderate amounts by those who wish it, for a 



388 DISORDERS OF NUTRITION. 

liter produces only 396 calories, while the same amount of rich 
milk produces 675 calories. Alcoholic beverages should be 
forbidden for the reasons already given. 

The diet just outlined can be stated more tersely as follows : 
Each day a patient may be permitted about 200 grams of bread, 
or approximately half a loaf; 350 grams of lean meat or other 
protein food, which could be an egg at breakfast, a French 
chop or its equivalent in size of other meat at noon, and a slice 
of cold meat of the same dimensions at night; 250 grams of 
vegetables and salads, which are equivalent to a baked potato, 
and a small saucer of peas, and a few leaves of lettuce or slices 
of tomato; 250 grams of fresh fruit, which 2 or 3 apples will 
equal; and 1500 c.c. of water, or approximately five glasses, 
Tea or coffee may be substituted for part of this water if desired. 
Such a diet will produce from 1300 to 1400 calories. 

Necessary as it is to reduce the amount of food eaten, equally 
necessary is it to consume, by work, some of the surplus fat of 
the obese body. A starvation diet will result in the disappear- 
ance of a portion of the stored fat to maintain the temperature of 
the body and the energy of the tissues. The fat will, however, 
be used faster if muscular work is done. When muscles have 
been made partly useless by obesity or have undergone atrophy, 
they can be restored to normal strength only by use. 

If the heart is weak, as is often the case, exercise must be 
taken with caution. The best results in the excessively stout 
are always gotten by carefully graded exercise. Active ex- 
ercise is preferable to massage. The latter may at first be em- 
ployed when active exercise is distressing or distasteful. The 
masseur should, however, introduce into his treatment numer- 
ous resistance exercises. The degree of resistance made should be 
increased little by little. As soon as possible the obese patient 
should be led to take active exercise, and for this to be effective, 
it must be sufficiently severe to cause perspiration. Oertel 
especially insists upon the need of exercise and its utility in 
reducing flesh. It insures a better circulation of blood, a 
better oxygenation of it because of deeper breathing, and there- 
fore more perfect metabolism, and stronger muscles, a more 
rapid consumption of fat, and a more rapid elimination of 
water by the skin and lungs. Of all forms of exercise, he 



OBESITY. 389 

thinks hill climbing is the best. Such exercise is easily graded 
by prescribing the distance to be walked and the time during 
which the walk is to be taken. In this way exercise may be 
adapted to weak hearts as well as to strong ones. Hill climbing 
insures the elimination of larger quantities of fluid than any 
other exercise commonly used. This elimination in itself 
reduces weight. Even if a portion of the lost fluid be replaced, 
the new fluid will come to the tissues ready to take into solution, 
and in turn to eliminate from them, larger amounts of waste. 
Those patients who are strong, and especially those whose 
hearts are strong, should be encouraged to take gradually longer 
and more rapid walks and finally trots. A run upon a level, 
with a sweater on, will produce almost the same results as 
climbing steep and long hills. 

Hot baths, either tub, Turkish, or Russian baths, are some- 
times employed to produce free elimination by the skin. They 
do not, however, produce effects comparable to those that can 
be obtained from exercise. 

The alkaline mineral waters are often given for their effect 
upon general nutrition. Undoubtedly they do benefit those 
afflicted with gout. Drinking water copiously, especially 
alkaline water, stimulates more rapid and perfect metabolism. 
Bouchard claims that alkaline sulphur waters act upon the 
liver and promote greater elimination of fat. Purgative waters 
are also useful, especially for those with enormous abdomens. 
Various drugs have been used to influence general nutrition 
and to hasten the loss of flesh. But most of these produce no 
positive effect. Desiccated thyroid may be used with ad- 
vantage as an adjuvant to diet and exercise for it undoubtedly 
causes a reduction in body weight. If given in large doses, 
however, it will lessen appetite, and cause nausea, rapid action 
of the heart, and loss of strength and endurance. It is safest 
to begin with moderate doses — one and one-half or two grains, 
but these doses may be gradually increased. Watch should be 
kept over the effect of the drug upon the heart, as it may cause 
distressing cardiac weakness. I have many times given 
strophanthus or digitalis with thyroid extract when I desired 
to get the fullest effect of the latter, in order to counteract the 
quickening and weakening action of the drug upon the heart. 



390 DISORDERS OF NUTRITION. 

Thyroid should be used only when there is no organic disease of 
the heart or of the great vessels and should not be used long. 

Not all cases of obesity can be treated alike. The general 
principles of treatment that I have described must be applied 
to each with discrimination. 

Obesity in childhood rarely requires treatment for it is out- 
grown in almost all cases. After middle life a rapid reduction 
in weight should not be attempted or only in those who are 
especially vigorous, but a slow or intermittent reduction is 
possible and will greatly benefit them. The effect of treatment 
upon the heart's strength and upon the activity and health of 
the kidneys must be watched closely. 

The treatment outlined above is applicable to the obese who 
are florid and strong. However, there are a large number of fat 
persons who are anemic and who cannot be given so restricted a 
diet and so much exercise. These cases are often helped by the 
treatment advised by Weir Mitchell, which is as follows: The 
patient should rest in bed for two weeks ; during the next two 
weeks he may walk about a little, but should still spend much 
time upon the lounge. Massage once or twice daily, later 
combined with more active, Swedish movements, should be 
given. During the first five or six days of treatment the 
patient's ordinary diet is gradually changed until he is gotten 
upon an exclusive skimmed milk ration. If drinking milk 
only becomes very monotonous, it is varied by permitting a 
little of beef, chicken, oysters, or clam soup. Upon skimmed 
milk, patients often lose half a pound or more a day. Care 
must be taken, if the heart grows too quick and weak because 
of rapid depletion, to feed more generously. Meats, fish, and 
eggs constitute the first change from the skimmed milk to an 
ordinary diet. While upon this diet anemic patients must 
be given iron. Rest in bed with only passive exercise at first 
will enable many feeble patients to bear a rapid loss of flesh that 
they could not stand if they were up and taking active exercise. 

When obesity has caused cardiac weakness, graduated ex- 
ercise should form an essential element of treatment. Oertel's 
plan, which may be carried out at home or at one of the "Ter- 
raincurorte, " is particularly well adapted to the needs of these 
patients. 



OBESITY. 391 

Those who are active and vigorous and only moderately 
overweight can be treated at home and sometimes even their 
usual avocation need not be interrupted, but when it is neces- 
sary to remove many pounds and especially if the heart is weak 
or other organs are not normal it is best that the patient give 
himself wholly to the cure. He is more certain to do this at a 
sanitarium or health resort than at home. However, resort to 
neither of these is necessary. Usually six or eight weeks are 
required to effect satisfactory results and often a longer time 
devoted to a modified treatment at home may be required. A 
permanent and persistent change in habits of eating and ex- 
ercise are commonly requisite to maintain the reduction which 
may have been effected. 

Those who are only moderately overweight frequently can 
be sufficiently reduced and the reduction maintained by first 
inquiring in detail into their habits of eating and by then cutting 
out one or two or a few of the carbohydrates which they habitu- 
ally use. 

The sample diets quoted below are interesting types: 
Ebstein recommends the following: 

Breakfast : A cup of black tea without sugar or milk, and two ounces 
of buttered toast. 

Dinner: A meat soup or broth, from four to six ounces of boiled or 
roasted fat beef with meat gravy, not thickened; one or two fresh 
vegetables in moderation, and salad and fresh or dried fruit. A little 
light wine and black tea without milk or sugar. 

Supper: Tea as before, a soft-cooked egg, a little fish, ham or cold fat 
meat, an ounce of thin buttered bread or toast and fresh fruit. 

Oertel's diet for the obese is as follows: 

Morning: One cup of coffee or tea with a little milk and about three 
ounces of bread. 

Noon: Three or four ounces of soup, seven or eight ounces of roast or 
boiled beef, veal, game or poultry, not too fat, salad or a little vegetable, 
fish, if desired, from one to three ounces of bread or farinaceous pudding, 
from three to six ounces of fruit. Drink nothing at this meal, or, if the 
weather is very hot, six to eight ounces of light wine. 

Afternoon: Coffee or tea as in the morning, and not to exceed six 
ounces of water; rarely an ounce of bread at this time. 

Evening: One or two soft-boiled eggs, an ounce of bread, perhaps a 
little cheese; salad or fruit; from six to eight ounces of wine with four or 
five ounces of water. 



39 2 DISORDERS OF NUTRITION. 

Schleicher recommends : 

Morning: 7 a. m., a mutton or veal cutlet, or a portion of sole as big as 
the palm of the hand; the same quantity of bread without butter. 8 
A. m., a cup of tea with sugar. 10.30 a. m., a sandwich of bread and meat. 

Afternoon: 1 p. m., meat, eggs, green vegetables, cheese, an orange; 
two glasses of white wine. 4 p. m., tea with sugar. 7 p. m., a small 
quantity of bread and cheese. 9 P. m., cold meat, eggs, salad; two glasses 
of wine. 

Another menu is : 

Breakfast: 9 a. m., five or six ounces of meat (except pork or veal) or 
fish; a little biscuit, or one ounce of dry toast, a cup of tea or coffee with 
milk or sugar. 

Dinner: 2 p. m., fish or meat (avoiding salmon, eels, herring, pork, 
and veal) ; five or six ounces of poultry or game; any vegetables except 
potatoes, parsnips, beets, turnips, or carrots; dry toast, one ounce; 
cooked fruit unsweetened, claret, sherry, or Madeira. 

Tea: 6 p. m., cooked fruit, two or three ounces, a rusk or two; from 
two to four ounces of solids; nine ounces of tea without milk or sugar. 

Supper: 9 p. m., meat or fish as at dinner, three or four ounces; claret 
or sherry and water. 

The foods of those attempting a reduction in weight or 
desirous of maintaining a reduction already attained must 
consist of meats, fish, eggs, such vegetables as artichokes, 
asparagus, beets, brussel sprouts, cabbage, cauliflower, carrots, 
celery, cucumbers, dandelion greens, eggplant, endive, lettuce, 
mushrooms, onions, parsnips, radish, rhubarb, spinach, squash, 
string-beans, tomatoes, turnips, watercress, fruits of all kinds, 
except dates, figs and raisins and very sweet dried or preserved 
fruits. 

Sugar, bread, cereals and other foods rich in starch and sugar 
must be forbidden or limited by judicious prescription. 

RACHITIS 

Causes 

Rachitis, a disease of childhood, is a fault of nutrition that is 
most frequently caused by improper or insufficient food, and 
rarely by inherited weakness of digestion or other inherited 
disease. Parrot insists that rachitis is often a manifestation of 
inherited syphilis. Some children are undoubtedly born with 
it. It is acquired both by sucklings and by bottle-fed babies. 



RACHITIS. 393 

A variety of conditions may influence the quality of mother's 
milk and make it unsuitable for the proper nourishment of an 
infant. The nurslings of mothers who have been weakened by 
frequent pregnancies are apt to develop rachitis. Other con- 
ditions that weaken mothers, such as acute or chronic illnesses, 
will produce the same result. The loss of sleep, emotional or 
neurotic disorders, or errors of diet will similarly affect a mother's 
milk. 

Rickets has been produced artificially in young animals by 
depriving them of animal fats and earthy salts, especially of lime- 
salts, such as the phosphates. When too little lime is furnished 
in food, the balance required is absorbed from the bones; as 
these have already ossified, they become weakened and softened 
by the withdrawal. The presence of lactic acid or phosphorus 
in the food hastens these results. 

There is some experimental evidence that the parathyroids 
and possibly the thymus glands are related to calcium meta- 
bolism. These facts also suggest a possible relationship be- 
tween rachitis and osteomalacia and the functional activity 
of these glands. McCallum and Voegtlin have shown that 
when the parathyroids are removed calcium is excreted in ex- 
cessive quantities and the percentage in the blood and tissues 
is reduced. Moreover, they and other observers have shown 
that the teeth and bones no longer calcify normally or cease to 
grow. On the other hand if this condition is experimentally 
produced by the removal of the parathyroids from animals the 
transplantation of these organs into them corrects the dis- 
turbed calcium metabolism. And if tetany has been provoked 
it can be stopped by injections of lime-salts. 

Bedt and Klose have observed changes analogous to rachitis 
in young dogs from whom the thymus had been removed. 

These experiments doubtless throw some light upon the 
pathology of these diseases but do not explain its treatment. 

Starches and sugars are unsuited to form the principal part 
of an infant's food, because they are wanting in lime and liable 
to be converted into lactic acid in the stomach. Many 'infants' ' 
foods upon the market are not only unsuited for those who 
have rickets, but will even cause the malady, because they con- 
tain too much starch and sugar and too little earthy salts. 



394 DISORDERS OF NUTRITION. 

This ailment is especially apt to develop in infants during 
their second year, or during the last part of their first year, when 
they are nursed and at the same time fed a variety of foods that 
they are not yet old enough to digest. 

Rachitis is best prevented by having children nursed only by 
healthy mothers or wet-nurses sufficiently intelligent and con- 
scientious to take proper care of themselves. When it is 
necessary to feed babies from a bottle, only good milk should 
be used, and during the earliest months of infancy modified 
milk is to be preferred. The milk mixture should contain 4 per 
cent, of fat and from 5 to 7 per cent, of milk-sugar, and during 
the first few weeks of life from 1/2 to 1 per cent, of protein. 
Lime-water should be added to this mixture to insure a faint 
alkalinity, and to secure to the child enough lime for its good 
nutrition. It has been estimated that an infant four months 
old should get at least fifteen grains of calcium daily. It is 
well, as the nurslings grow, to supplement the milk by ad- 
ministering daily a little calcium phosphate or lactophosphate 
in some other manner. 

Milk should be modified month by month to meet the chang- 
ing requirements of the child. By so doing the little one can be 
well nourished. The milk should be pure and free from dirt. 
If the herd of cattle from which it is obtained is not known, and 
the method of milking and of handling the milk is such as may 
not insure unusual cleanliness and purity, it should be Pasteur- 
ized when first received. During the first three or four months 
of childhood starches should not be mixed with the milk. 
Barley and oatmeal water, which contain comparatively small 
amounts of starch, are sometimes employed as diluents when 
the facilities are not at hand to modify milk properly, because 
they partly prevent the formation of large curds during the pro- 
gress of digestion. 

To prevent rickets it is absolutely necessary to break the 
habit so common with those who are ignorant and heedless of 
giving to infants and very small children a little of everything 
eaten and drunk by vigorous adults. Nothing is more certain 
to engender the disease than this. It is also important that 
the home of the child should be clean and filled with fresh, 
pure air. 



RACHITIS. 395 

Treatment 

When children have developed rickets, it must be remembered 
that they need fats, not starches. The latter should be with- 
held until the child is beyond the age when they are usually 
given. Cream is a form of fat that is especially appropriate. 
Cod-liver oil is also a remedy of established reputation in these 
cases. Children a year or more old may also be given butter, 
and bacon cooked to a crisp. Inunctions of oil are also bene- 
ficial. Olive oil and cotton-seed oil are most used. Cod-liver 
oil is preferable, but its disagreeable odor often makes it un- 
available. 

Although it is best to withhold starches from such infants for 
a longer time than is usual, mutton broth, chicken broth, and 
beef-juice may be given after the sixth month. Orange-juice 
is also grateful and beneficial. After the twelfth month stale 
bread and crackers may be tried cautiously. Scraped beef and 
a soft-cooked egg may also be added to the diet, and gradually 
other fruit- juices or jellies. 

Rickety children usually being anemic and peculiarly suscep- 
tible to cold, it is of great importance that they should be so 
clothed as to be well protected; but care must be taken not to 
burden them with clothing in warm weather. While enfeebled 
they are nervous and excitable. They should then be guarded 
against undue excitement. As quiet a life as possible should 
be prescribed for them. 

As in all ailments, cleanliness and fresh air are essential. A 
residence of several months at the seashore during the summer 
is especially beneficial. Next to the suitable adjustment of 
food to the child's needs, a climatic change is the most im- 
portant aid to the successful treatment of the disease. The 
child should have a daily salt bath. If old enough, it should 
be allowed to play upon the beach in the sunshine, dressed 
in a flannel bathing suit, and encouraged to run in and out 
of the water, to sit down in it, roll over in it, and play 
vigorously in it and by it. It is probable that the sun and 
air baths are as important elements of this treatment as the 
sea-water. 

Hypophosphite, lactophosphate, and glycerophosphate arc 
the most eligible preparations of calcium for administration 



396 DISORDERS OF NUTRITION. 

in these cases. When anemia is a prominent symptom, various 
preparations of iron may be used advantageously. 

Louis Starr recommends the following menu for a child of 
eighteen months : 

Meal at 7.30 a. m. — Eight ounces of milk with a tablespoonful 
of cream added and on alternate days the yolk of a soft boiled 
egg with a little butter, salt and broken bread and two to four 
tablespoons of well-cooked and strained cracked wheat porridge 
with cream and salt. 

Meal at 11 a. m. — Eight ounces of milk with a tablespoonful 
of cream and a slice of whole wheat bread. 

Meal at 2 p. m. — A good tablespoon of well minced chicken 
or mutton with gravy and a little crumbled stale bread; a 
tablespoonful of puree of spinach, stewed celery or cauliflower 
tops; bread and butter. 

Meal at 6 p. m. — Milk and cream as at 7 and 11 a. m.; thin 
bread and butter. 

Pure water to drink. And avoid excess of farinaceous food. 

If diarrhea with liquid, offensive stools complicate the con- 
dition he would give a minimum of casein by substituting 
equal parts of veal or chicken broth and barley water for some 
of the milk feedings and for others give a mixture of cream, one 
tablespoon and freshly prepared whey six ounces. 

OSTEOMALACIA 

Osteomalacia has been called the rickets of advanced life. 
It is, however, characterized by a decalcification of bone, while 
in rickets the bone fails to calcify during the period of growth. 

At first the bones that are affected are painful. They be- 
come brittle and liable to break or to bend, and thus to produce 
deformities. The disease usually progresses steadily and does 
not permit of a favorable prognosis. 

It attacks women much oftener than men, usually between 
the ages of twenty and fifty. Pregnancy is a condition that 
especially predisposes to this disease, sometimes manifesting 
itself before and sometimes after the child's birth. It is of com- 
paratively frequent occurrence in certain localities, notably in 
Lombardy, the Black Forest, and in Flanders, while equally 



OSTEOMALACIA. 397 

rare in other localities. A parasitic origin has been suggested 
for it, but not demonstrated. Bouchard teaches that an excess 
of lactic acid in the blood dissolves the lime-salts of bone. That 
calcium may be removed by lactic acid in the blood has been 
proved by experiment, but that there is always an excess of 
this acid in the blood in cases of osteomalacia has not been 
demonstrated. 

Although due in the first place to a fault of nutrition, this 
disease will not be helped so much by diet as one might expect. 
Of course, foods rich in phosphates and mineral salts are espe- 
cially indicated for use. Such are eggs, meat, cereals, and milk. 
At the same time, however, care must be taken that too much 
lactic acid is not generated by abnormal fermentation in the 
stomach. Of meats, beef, mutton, venison, rabbit, and fowl 
are richest in salts. 

Phosphates, especially calcium phosphate, should be given to 
counteract the decalcification produced by the disease. Of the 
various phosphatic preparations, the compound syrup of 
phosphates, calcium hypophosphite, and calcium glycerophos- 
phate are among the best. Cod-liver oil is also recommended. 

Salt baths and other hydrotherapeutic measures are often 
beneficial. Good hygienic surroundings are essential. A 
residence upon dry ground and the wearing of warm clothing 
should be insisted upon. Necessarily, violent movements 
must be avoided, as they are liable to break the brittle bones. 
Often surgical treatment must be resorted to in order to cor- 
rect deformities. 

SCURVY 

Causes 

Scurvy is a disease of nutrition caused by the absence of 
certain ingredients from the diet of those who are affected with it. 
It is particularly apt to appear among those persons who live 
on insufficient food and in crowded houses, and amid filth. 
Hence its prevalence during periods of famine, in besieged 
cities, among those who are shipwrecked, or on voyages of 
unusual duration. But although bad ventilation, dampness, 
and overcrowding are often predisposing causes, they arc not 



398 DISORDERS OF NUTRITION. 

factors in every outbreak; the character of the food eaten is 
also of the greatest importance. Even too little food has caused 
scurvy. It has frequently appeared, however, when food 
enough was eaten, but when there was not enough of fresh foods. 

Scurvy or a disease like it has been produced experimentally 
by Hoist and his co-laborers in guinea-pigs by feeding them 
exclusively on grain or bread and in hogs by feeding them on 
rye bread with occasionally boiled beef or by feeding them on 
rice and dried fish. He also produced it in dogs by feeding 
them exclusively on oatmeal and beef fat. This experimental 
scurvy was preventable or removable by a more varied diet 
and especially by feeding the guinea-pigs cabbage, carrots and 
dandelions. What the exact nature of the antiscorbutic in 
foods is has not yet been demonstrated (Hoist and Froelich, 
Zeit. /. Hyg. u. Infections-krank, 19 12). 

Among civilized people a lack of fresh vegetables during a 
long period of time will cause the disease. For these reasons 
care is now taken that soldiers, sailors, and those confined in 
prisons and public institutions are furnished the needed modi- 
cum of fresh vegetables and fruits. It has been supposed that 
the absence of such acids as citric, malic, lactic, acetic, and 
tartaric was its cause. This cannot be, because there are 
savages who never eat vegetables and fruits and yet do not 
know what scurvy is. This is notably true of the Eskimos. 
They constantly provide themselves with fresh meats, however. 
Freshness is apparently the most important quality of food to 
prevent scurvy. This conclusion is still further strengthened 
by the fact that scurvy is not infrequent among infants fed 
exclusively or chiefly on proprietary foods. Morrow's experi- 
mental scurvy is not preventable or is less so and less amend- 
able to treatment by antiscorbutic foods which have been long 
preserved or dried than by fresh ones. Garrod teaches that 
scurvy is due to a deficiency of potassium in the blood, because 
in certain cases at least he found it deficient. It has not, 
however, been proved that there is always a lack of this salt 
in scurvy. 

It is a disease that often occurs epidemically in communities 
when the conditions for its development are present. It has 
been known to attack most of the inmates in a prison at one 



SCURVY. 



399 



time. It was widely prevalent in Ireland and England during 
the years of the 'potato famine. ' It is more prevalent among 
adults than among children, and commoner among men than 
among women, for each of these classes is exposed to its causes 
in a different degree. 

Scurvy is recognized by anemia and loss of flesh and strength. 
Hemorrhages occur beneath the skin, from mucous membranes, 
most noticeably from the mouth and nose, and sometimes into 
solid tissues, such as muscles, and into serous cavities and 
joints. The gums are swollen and inflamed. The teeth often 
become loose and drop out. The hair falls. The skin grows 
rough and scaly. Appetite is wanting. Patients become 
listless and depressed. The cutaneous hemorrhages appear as 
extravasations of various size, some pinhead like petechia, 
some as lafge as a nickel or larger. They develop first upon 
the extensor surfaces of the extremities. Hemorrhages some- 
times are so extensive as to endanger and even to terminate 
life. Patients may be entirely free from fever or show slight, 
variable elevations of temperature. Scurvy is rarely seen to- 
day, for the managers of prisons, poor-houses, and ships are now 
required by law to furnish those under their care with the 
needed amount of fresh food. Preserved vegetables and fruits 
can take the place of fresh ones, but should not be relied upon 
exclusively for any long periods of time. Although an uncom- 
mon disease, it may occasionally appear in communities where 
one would not expect it. For instance, during 1893-94 many 
patients suffering from it were seen in the hospitals of Chicago, 
who had acquired the disease while at work upon the Chicago 
drainage canal. Several came under my own care and were 
successfully treated in Mercy Hospital. Large numbers of 
foreigners worked upon this enterprise, who were housed and 
fed most unhygienically by the contractors employing them. 

The prophylactic measures that must be enforced to prevent 
scurvy consist in providing those liable to it with fresh meat, 
vegetables, and fruits, or at least canned vegetables, fruits, and 
fruit- juices. Before canned goods were placed upon the market 
the cheaper fruit-juices, and especially lime-juice, were relied 
upon. 

Infants should be given fresh milk rather than those prepared 



400 DISORDERS OF NUTRITION. 

foods that do not contain it. To bottle-fed babies, four months 
or more old, orange-juice in small quantities can be given with 
benefit. 

Treatment 

Mild attacks of scurvy can be cured by diet. Lemons and 
oranges should be given freely, with lettuce, spinach, cabbage, or 
sauer-kraut, pickles, tomatoes, baked or mashed potatoes, peas, 
string-beans, or other easily digested and simply prepared fresh 
foods. If the patient is placed in a well- ventilated, clean, and 
dry room, and given such food, recovery is quickly effected 
without other aid. 

When an attack is severe, the mouth is oftentimes too sore 
and tender to permit of mastication, and appetite is wanting. 
Care must then be taken that liquid and very soft foods only 
are used. Fresh milk, meat- juice and broths, and the juice of 
several lemons or oranges should be given. Usually purees 
of fresh vegetables can also be eaten. The patients should be 
fed small amounts, frequently, until appetite returns and 
digestion is restored to a good condition. 

The patient's mouth should be kept clean by frequent wash- 
ing or rinsing with mild antiseptic and astringent solutions. 
While feeble, he should be kept in bed. A salt bath or a shower 
bath, or a tepid bath, or, if well tolerated, a cool sponge bath, 
is a useful stimulant and improves nutrition. 

Ferruginous preparations assist in restoring the blood to a 
normal condition. Such potassium salts as the bitartrate and 
citrate are used with benefit. Mild laxatives are sometimes 
needed. Drastics must be avoided, for they may provoke 
intestinal hemorrhages or precipitate diarrhea. 

BERI-BERI 

This disease is seen rarely in the United States but has been 
prevalent in the Philippines and in most Oriental countries. 
It is not only common there but very fatal. Foods have long 
been blamed for its production. That it occurred oftener 
among those who ate almost exclusively polished rice than 
others has been observed in many places and first lead to the 
suspicion that rice was its cause. When in the Japanese navy 



BERI-BERI. 40 r 

meat was added to the sailors diet the disease which had been 
very prevalent lessened and almost disappeared. Elsewhere it 
was observed that if other vegetables rich in phosphorus were 
eaten with rice the frequency of beri-beri lessened. 

John M. Little has described Beri Beri in Newfoundland- 
He sees cases of it frequently of late years, especially at certain 
seasons, when the inhabitants live exclusively on bread and 
tea. Formerly when they used whole wheat bread the disease 
did not exist but since fine wheat flour has been used the disease 
has appeared. It is curable by a mixed diet and good hygienic 
surroundings. (Jul. Am. Med. Ass. June 29, 19 12, p. 2029.) 

Frasar, Stanton and others have shown that a disease similar 
clinically and anatomically to beri-beri can be produced in fowls 
by feeding them on polished rice. It has also been shown that 
in its early stages this experimentally produced disease can be 
cured by feeding the birds meat with rice or by adding the 
polishings or bran to the rice. 

Drs. Chamberlain and Vedder, members of the United States 
Army studying tropical diseases as they exist in the Philip- 
pine Islands, state that the pathology and symptom-com- 
plex of the two diseases, polyneuritis gallinarum and human 
beri-beri, are practically the same with the exception that 
edema is commonly observed in beri-beri and only rarely 
found in the multiple neuritis of fowls. The similarity, they 
remark, is so striking that it is hard to avoid the conclusion that 
the two conditions are due to the same pathologic process caus- 
ing, as might quite naturally be expected, slightly different 
manifestations in diverse species. The surprising thing is not 
that there are minor differences in symptomatology, but rather 
that the similarity is as great as it is. This lends great import- 
ance to the use of fowls in the experimental study of tin- etii '1' gy 
of beri-beri. 

More recently men afflicted with the malady have been cured 
by a change from a diet of polished rice to meat and other 
vegetables. It has also been observed that in groups ti men 
some fed on polished rice and others upon unpolished v'w 
disease did not appear among the latter but did MQOdg fehe 
former. All these facts leave no doubt of the causative relation- 
ship of polished rice to the disease. 
26 



402 DISORDERS OF NUTRITION. 

Polished rice is made by modern milling machinery which 
removes the husk and leaves only the white starch of the 
center of the grain. With the husk, fat and phosphorus com- 
pounds are also removed. Although the relative proportion 
of phosphorus compounds in rice is a good criterion of its whole- 
someness as a food, experiment does not warrant the belief 
that the lack of phosphorus is the cause of beri-beri. For the 
administration of phosphorus, phosphates and other mineral 
salts does not cure or prevent the disease. 

During the last year it has been shown that the substance 
which prevents beri-beri when unpolished rice is eaten is soluble 
in water, in alcohol and in o . 3 per cent, of hydrochloric acid. 
Moreover, it has been shown to be a substance which will not 
pass through a dialyzer. Funk believes that it is an organic 
base which is completely precipitated by phosphotungstic 
acid, by silver nitrate and baryta. It occurs in very minute 
quantities, there being not more than o . 1 grams per kilo of rice. 1 
These are important facts and throw light on the nature of the 
cause of the disease. 

Although until recently beri-beri has been regarded as a 
most fatal malady it is now shown to be curable, if treated 
early, and quite preventable. For its cure a mixed and varied 
diet, generous in meat and phosphorus-bearing foods, is needed 
and the exclusion of polished rice. Rice polishings when fed 
to birds in whom this form of polyneuritis has been produced 
will cure the disease, as will a more varied diet; especially one 
containing meat. The dose of the material in rice polishings 
which will cure pigeons is minute, according to Funk not more 
than .004 gram. 

It is significant that according to Hulshoff-Pol and Chamber- 
lain and Vedder, decoctions of white beans cure polyneuritis in 
fowls. The same substance which is present in the rice millings, 
or a similar substance, is present in a decoction of ordinary 
white beans; in fact, bodies corresponding to them are 
found among the decomposition products of the proteins. 
These facts are of importance, since they suggest that beans 
can be used as a preventive of beri-beri, in the rations of the 

1 Funk: "The Chemical Nature of the Substance which cures Polyneuritis in Birds 
induced by a Diet of Polished Rice." Journal Physiology, 191 1, XLIII, 395. 



BERI-BERI. 



403 



native Philipine troops, native prisoners and others whose diet 
by preference consists largely of rice. This is a useful discovery 
because if the natives do not care for mongos, or the other arti- 
cles introduced into the ration for the purpose of preventing 
beri-beri, they will not eat them, but will live on an almost 
exclusive diet of rice; however, the man, native or white, who 
does not relish well-cooked beans is hard to find." W. H. 
Jefferys has (Jul. Am. Med. Ass. July 12, 191 2, p. 201) called 
attention to the fact that H. W. Boone, of the staff of St. Lukes 
Hospital, Shanghai, and others have relied upon beans for ten 
years to effect a cure in this disease. 

V. G. Heiser in "Medical Observations in Islands of South 
Pacific Ocean" describes symptoms of an infantile disease which 
is probably beri-beri of infancy. 

"The mothers have all had symptoms of incipient or marked 
beri-beri. A number of these mothers have previously had 
infants die with symptoms similar to those presented by the 
children which were studied. In every case the diet of the 
mother had been chiefly highly milled rice with a little fish and 
occasionally a bit of meat. The children have all been breast 
fed. With one exception all have been under three months of 
age. The disease usually has been ushered in with vomiting, 
which after a few days was followed by great restlessness, sleep- 
lessness, continual whining and later by dyspnea, increased 
cardiac action and edema of the face and legs. Later still, 
oliguria and aphonia developed in many of the patients. About 
one-half of those treated had aphonia, and some appeared to be 
at the point of death. On the other hand, several cases were 
milder. 

"The infants were all given twenty drops of the extract of 
rice polishings every two hours while awake, and the results 
have been truly marvelous. Improvement is immediate. The 
vomiting stops in twenty-four or thirty-six hours. The child, 
who has not passed any urine for several days, urinates five or 
six times freely. The edema disappears in the course of a few- 
days. Usually on the first night after treatment is begun the 
infant falls into a deep sleep, although it may have been 
practically sleepless for several weeks. The dyspnea and palpi- 
tation cease after two or three days. At the end of a week, or 



404 DISORDERS OF NUTRITION. 

in less time, the patients are completely cured with the excep- 
tion of the aphonia. The mother is positive that the baby is 
well and she would be completely satisfied if only it would 
recover its voice. The aphonia, however, does not disappear 
until after about two months of treatment, when the voice 
usually returns quite suddenly. This is probably due to the 
fact that the aphonia is caused by degeneration of the pneumo- 
gastric nerve, which only slowly regenerates."'. These results 
have been confirmed by Chamberlain and Vedder. 

To prevent beri-beri the use of polished rice (and probably 
the use of finely milled wheat) as an exclusive diet must be 
forbidden or better still its manufacture and sale prevented. 

It seems probable that beri-beri which has been so common 

and so fatal in the Orient may be made as rare as it was common 

and possibly may be exterminated by dietetic management and 

by the correct manufacture of rice as a food. 

i ■ ' . 

DIABETES 

The cause of diabetes can rarely be removed. Occasionally 
cases are met in which glycosuria has been provoked by the 
excessive use of sugar and starch. These can be cured radically 
by limiting the ingestion of carbohydrate foods. The severity 
of all cases of diabetes is increased by prolonged mental depres- 
sion or great anxiety, or other strenuous and not exhilarating 
mental states. These conditions sometimes are the exciting 
cause of the sickness ; more frequently they provoke relapses or 
aggravate it. The patient's mode of life should be regulated so 
as to correct and avoid these states. Sciatica and other troubles 
involving the peripheral nervous system are apparent causes of 
diabetes in some cases; in others, its result; though often the 
first symptoms to attract attention. Structural disease of the 
medulla, brain, or cord may apparently give rise to the symp- 
tom-complex. Destructive or functional inactivity of the 
pancreas also has been demonstrated to be a cause of many 
cases of it. It is at times associated with hepatic lesions 
Sometimes, however, no definite structural lesion in nervous 
system, liver, or pancreas can be found. 

Nutritional changes characterize all cases. In well-marked 
instances all metabolic processes are increased; in the mildest 



DIABETES. 405 

cases, those of the liver only, or at least the most persistently. 
The daily output of urea is increased, although it can be 
demonstrated that nitrogenous food is well utilized. The 
nonnitrogenous foods are imperfectly oxidized. Oxyhemoglobin 
is increased in the blood. Carbonic acid gas is expired in larger 
volume than is normal, and the absorption of oxygen is aug- 
mented. The combined sulphates and hippuric acid are in- 
creased. In some cases the body waste, in spite of the eating 
of large amounts of food, shows that retrogressive metabolism 
exceeds reparative changes. In the severest cases sugar is 
made from protein. Von Noorden believes that the liver 
is unable to make glycogen and it is certainly almost entirely 
absent from the liver in severe cases. 

For convenience in discussing the diet of diabetics we can 
group cases under three heads: first, the mildest; second, the 
moderate; third, the severe cases. Acute cases, which are seen 
almost exclusively in childhood and early adult life, belong to 
the last group, as do some of those chronic from the start. 
Mild cases may gradually grow more severe. Not infrequently 
a case is from its inception of moderate or of severe type. 

In those cases that can be called mildest, the patient will 
cease to eliminate sugar in the urine when the ingestion of sugar 
is forbidden and the eating of starches is limited. They usually 
occur during or past middle life in persons disposed to obesity 
and goutiness, and readily yield to treatment. The moderate 
cases are those of patients from whose urine sugar can be re- 
moved by withholding all foods containing either sugar or 
starch. The severe cases are those of patients from whose 
urine sugar cannot be removed by depriving them of carbohy- 
drate food. Sugar can be made to disappear from the urine of 
some of these by depriving them entirely of carbohydrates and 
at the same time limiting the amount of albuminous foods. 
In others the same thing can be accomplished by careful dieting 
and medicinal treatment. There are many patients, however, 
from whose urine the sugar cannot be made to disappear by any 
treatment. 

It is necessary to prescribe carefully and definitely both the 
character and the quantity of food that diabetics shall take. 

First, in order to ascertain to which of the Qj s de- 



406 DISORDERS OF NUTRITION. 

scribed a given case belongs, the patient must be placed on the 
diet from which sugars and starches are absolutely excluded. 
However, this strict diabetic diet — that is, one containing no 
carbohydrates — should be instituted gradually, as in many 
cases coma has been brought on by a sudden and complete 
change, while in other cases indigestion has been caused by it. 
From the beginning all sugar should be forbidden, and the amount 
of starchy food should be diminished slightly. The latter 
should then be further lessened day by day during the first 
week of treatment, so that, if the patient's condition permits, 
all starch will be excluded by the end of that time. Simul- 
taneously with the diminution of carbohydrate food, albumin- 
oids, and especially fats, should be increased. The total 
quantity of urine for twenty-four hours and the percentage of 
sugar that it contains should be ascertained at least every 
second or third day. Moreover, Gerhardt's test with ferric 
chlorid must be made frequently. If it gives a positive reaction, 
or if there is other evidence of acetone or diacetic acid in the urine, 
a modification of the strict diet should be made at once. In- 
deed, it is safest to enforce Ebstein's rule that under these con- 
ditions the amount of albuminoids eaten should be lessened and 
the amount of carbohydrates increased. The presence of the 
acetic compounds in the urine signifies a great liability to 
diabetic coma. If the reaction is found when severe cases first 
come under treatment, sugar only should be excluded from 
the diet and the amount of albuminous food should be limited. 
At the same time the intestines should be cleansed and albu- 
minous indigestion, if it exists, corrected. Alkaline salts and 
alkaline mineral waters are also useful under these circumstances. 
They may have to be given hypodermically if any quick results 
are required. 

Acetone, diacetic acid and oxybutyric acid are due to the 
breaking up of fatty acids. When they are generated in 
large quantities they produce or are associated with an acidosis 
or the phenomena of diabetic coma. Alkalis neutralize the 
acid and help to prevent or to overcome the acid state. The 
administration of carbohydrates in some unknown way also 
prevents the formation of acetone, diacetic acid and oxybutyric 
acid even when fats are eaten in generous amounts. This is the 



DIABETES. 407 

reason for at once adding carbohydrates to the diet when 
diacetic acid is found in the urine in large quantity or persist- 
ently. It is safest also to restrict very considerably the 
amount of fat which such a patient is to eat and somewhat also 
the amount of meat. Van Noorden's oatmeal diet particularly 
is a good one under these circumstances. 

The mildest cases are discoverable by the disappearance of 
sugar from the urine before all carbohydrates are withdrawn, 
and in such cases the strict exclusion of this class of foods will 
not be necessary. In most cases of diabetes a certain amount of 
carbohydrate food may be eaten and will be utilized by the 
tissues. What this amount is can be determined only by ex- 
periment. Moreover, the ability of the same individual to 
utilize such food varies from time to time. It is rare that more 
than 100 grams (31/3 ounces) of carbohydrate in a day can 
be taken with safety. 

Those cases that belong to more severe types of the disease 
cannot be so quickly classified. The effect of more rigorous 
dieting and often also of medicinal treatment must be ob- 
served. That diet which, in the mildest cases, has been 
found to prevent glycosuria, must be continued as long as 
possible, or at least for several weeks. When cases are very 
mild, the dietetic limitation necessary is often so slight as to 
cause the patient no discomfort and to require little self-denial. 
But in those cases that approach the group of moderate ones 
not only does the persistent restriction necessary demand an 
irksome self-denial, but the excess of albuminoids and fats 
often lessens appetite greatly and causes indigestion. 

It should not be thought that a patient is cured because 
glycosuria does not return while he is upon a restricted diet. A 
genuine cure is rarely effected. Temporary recovery often 
occurs. When a restricted diet has been used for from six to 
twelve weeks, it may gradually be made more generous as 
regards carbohydrates. The mildest cases may be permitted 
a thin slice of bread at each meal, and the amount of this food 
may be increased for two or three days, and its effect ascer- 
tained by urinalysis. If it does not cause glycosuria, a baked 
potato may also be tried, and later a small quantity of some 
fruit that contains the least amount of sugar. It is only in a 



4P8 DISORDERS OE NUTRITION. 

very small number of cases that a full normal diet can be re- 
sumed after several months of treatment. Recurrences are so 
usual that it is necessary to enjoin perseverance in watching 
the urine. If it increases in amount, and especially if it pro- 
duces a feeling of stickiness when it dries upon any object, the 
patient should at once consult his physician. If appetite 
grows less, or weight of body diminishes, he should also place 
himself under guidance. It is best for all who have had gly- 
cosuria to have a urinalysis made from every four to six weeks 
for a year or two even after apparent recovery. In most cases 
recurrences take place from time to time, requiring careful 
treatment. 

If the diet that is necessary in moderate cases to prevent 
glycosuria cannot be long maintained, it is still less feasible 
in the severest cases, in which all sugar and carbohydrate food 
must be excluded, necessitating a diet exclusively of meat and 
fat. Such a diet soon causes a disgust for the foods permitted 
the patient, or dyspepsia, and often increased nitrogenous 
denutrition, which is already excessive. By a reasonable 
restriction of diet the percentage of sugar in the urine can be 
kept low. It must be remembered that sugar in the urine per 
se is not harmful. It is of importance only as it indicates the 
degree of disturbance of nutrition that exists. When, by 
suitable treatment of a moderately severe or a severe case, not 
more than 500 grains of sugar are voided daily, the case may be 
regarded as well controlled. 

Excellent results can often be had by intermittently restrict- 
ing the diet closely. From two to six times a year this should be 
done for from two to four weeks. In all cases it is well, on one 
or two days in every week, to place patients upon a diet limited 
in quantity and much restricted in character. For instance, 
if a patient is permitted a liberal amount of meats, nonamylac- 
eous vegetables, and a little bread, or occasionally a potato, 
it is well once in every five to seven days to prescribe a day of 
fasting, when only a modicum of albuminous food, a little salad, 
and other green vegetables are permitted. Especially at 
these times water should be drunk freely and if possible 
to some extent an alkaline water. These fast days and the 
longer periods of restriction previously referred to remove 



DIABETES. 



409 



for a time, or greatly lessen, the excretion of sugar in the urine. 
In prescribing these days and periods of fasting one must re- 
member what has already been said of the significance of 
Gerhardt's test and of disgust for food and of dyspepsia. 

To prevent too rapid nitrogenous denutrition, fats must be 
urged upon diabetics. They lessen the consumption of tissue 
albumin just as carbohydrates do. Unfortunately, they are 
not tolerated in quantities that will enable them fully to take 
the place of carbohydrates. Butter is well digested and should 
be eaten freely. Olive oil should be used generously upon 
salads. Fat meats, such as ham, bacon, pork, and mutton, 
should be eaten. If these meats must be eaten often they are 
best tolerated when eaten cold, except crisp fried bacon. 
Many clinicians prescribe cod-liver oil also, but this is not 
readily taken by patients. It is likely to cause indigestion and 
disgust and can rarely be taken in sufficient quantities to make 
it very useful. Many think that a small quantity of some 
alcoholic beverage that does not contain sugar will stimulate 
the stomach and facilitate the removal of fats from it, and 
therefore assist their more rapid digestion. I know of no 
experimental demonstration of this. It is undoubtedly true 
that many patients can take fats and oils in considerable 
quantities with more relish if they take also such an alcoholic 
beverage. To some extent condiments help in the same way. 

Meats, except liver, oysters, mussels, 1 and such shell-fish as 
consist chiefly of liver, may be permitted at all times, but they 
should not be cooked with flour or bread-crumbs. Eggs are 
especially useful. They contain 13 per cent, of protein and 11 
per cent, of fat. Meat, eggs, and fish must constitute the staple 
of a diabetic's diet. Cheese of all kinds is permissible. Some 
kinds contain a goodly amount of fat in an agreeable form. 
Butter contains 83 per cent, of fat, 0.7 per cent, of sugar, and 
0.86 per cent, of protein. It is, however, the most palatable 
of all fats, and can be taken in very large quantities with the 
greatest pleasure. It should be spread thickly upon bread or 
such substitutes for bread as may be prescribed. Cream also 
is agreeable, and may be permitted with benefit to most patients, 
although it does contain about 4 per cent, of lactose. Lbs 

1 Kleen and others permit shell-fish; oysters contain only a.6 per cent, of carboh\ 



4io 



DISORDERS OF NUTRITION. 



1 6 per cent, of fat makes it most desirable, and diabetics can 
often dispose of considerable quantities of milk-sugar, just as 
they can of levulose. Cream is often made more palatable by 
dilution with water, perferably such an alkaline water as 
vichy. 

Devonshire cream, which is liked by many, contains less than 
2 per cent, of lactose and 65 per cent, of fat. It is made by 
keeping the milk in large pans at a gentle heat for many hours. 
The temperature should be much below boiling. Under the 
influence of prolonged heat the fat coalesces and rises more 
rapidly than otherwise. Buttermilk contains about 3.3 per 
cent, of lactose. Kumiss contains from 1.6 to 2.8 per cent, of 
lactose, and kephyr, 1.5 per cent. Milk may be permitted to 
diabetics, except when a very strict diet is prescribed. It 
usually contains 4 per cent, of fat, 4.5 per cent, of lactose, and 
4 per cent, of protein. To some patients, however, it can be 
allowed only in small quantities, for a pint should contain an 
ounce and a half of milk-sugar, and certain individuals exhibit 
marked intolerance of this substance. 

Several substitutes for milk have been devised. I suggest 
the following as much the easiest to prepare : gravity cream con- 
tains 16 per cent, of fat, approximately 3 per cent, of sugar, and 
the same of protein. If it be diluted four-fifths with water, it 
will contain approximately 3 per cent, of fat and 0.5 per cent, 
of sugar and protein. To the water with which it is diluted 
sufficient egg-albumen can be added to make the total amount 
of protein approximate that of normal milk. The mixture can 
be sweetened with saccharin or levulose. This will make an 
agreeable drink, rich in fat, containing also a small amount of 
albumin, and about one dram of milk-sugar to the pint of 
beverage. 

All sugars do not seem to be equally harmful. The same can 
be said of starches. When glucose is eaten, it is most certain 
to appear at once in the urine of diabetics. Milk- and cane- 
sugar are somewhat better assimilated, and by most diabetics 
levulose can be taken in considerable quantity without harm. 
The latter, however, is too expensive to be used as a general 
substitute for cane-sugar. Saccharin is the most available 
sweetening agent, but must not be given in sufficient quantity 



DIABETES. 411 

to interfere with digestion. Honey must be forbidden, as 
must be cane- and grape-sugar. 

Starch, although converted into sugar during digestion, is 
less certain than sugar to aggravate a glycosuria. Still, starch 
and foods containing it must be forbidden when a rigorous 
diabetic diet is prescribed, and it should always be limited 
when not forbidden. This makes it necessary to exclude from 
the diet of the diabetic, flour products (bread, cake, pastry, etc.), 
cereal foods, rice, cornstarch, potato starch, arrow-root, sago, 
tapioca, hominy, macaroni, vermicelli, and farina. The follow- 
ing tables will show the percentage of starch in many of the 
common flour products : 

Protein Fat Carbohydrate 

Rice, dried 9.0 0.8 88 . 00 

Sago, dried 0.8 86.10 

Indian corn n. 7 5.5 77 .80 

Macaroni, dried 9.0 0.3 76.70 

Rye flour 12.8 2.3 81.30 

Wheat flour 10.5 1.3 87.10 

Oatmeal, dry 15.0 6.0 64.70 

Rye bread 6.1 0.4 49 .20 

Wheat bread 6.1 0.4 5 1 . 00 

Graham bread 6.0 0.3 39 .41 

English biscuits 7- 2 9-3 75 - IO 

Numerous substitutes for flour products have been recom- 
mended. As bread is the most difficult of all articles of food 
for diabetics to abstain from, these substitutes are a comfort 
to them. But such articles must not be eaten freely, since 
most of them contain too much fat, nor are they long relished 
when taken steadily. They are also for the most part expen- 
sive. The following table shows the relative percentage of 
important ingredients in some of the breads: 

Carbohydrate p AT Protein 

AND SUGAR 

Wheat bread 45*050 o . 2 to 8 6 to 7 

Gluten bread (commercial). 30 to 70 

Almond cakes 7 a 53 • 7 2 4 

Soya bread 3 to 2 3 

Cocoanut almost none 70 

Peanut 2 7 8 5 2 



412 DISORDERS OF NUTRITION. 

Of these, the cocoanut flour, and the almond flour make 
the best substitutes for wheat bread, inasmuch as from them 
the carbohydrate present — sugar — can be almost entirely 
removed by raising bread with yeast, and from the last nearly 
as well by washing it with acidulated water. Commercial 
gluten bread contains half as much carbohydrate as wheat 
bread and sometimes more. It is less palatable and less safe 
to give than a limited amount of ordinary wheat breads. The 
bread made of nut flours should be used very moderately, for 
it contains so much fat that it is not readily digested. More- 
over, patients tire of such breads after a few weeks. It is 
therefore well to shift from one nut flour to another, and to 
make a variety of bread, so that weariness of these preparations 
may be as long delayed as possible. The following receipt is 
recommended by O'Donnell as a substitute for home-made 
bread. It contains no starch or sugar, and will help to give 
variety to the diet : Beat six eggs thoroughly; add a teaspoonful 
of baking powder and a quarter as much of salt ; again beat the 
eggs. Pour the mixture into hot waffle irons smeared with 
butter. Bake in a hot oven. Eat hot with butter or flavor 
with cheese or nuts. 

Substitutes for home-made wheat bread should be used 
only while patients are upon a strict diet. 

It has been shown repeatedly that many with mild diabetes 
can take one kind of starch in moderate quantities without 
detriment and often others of a more severe type can be habit- 
uated to one kind, so that it will be tolerated without aggravat- 
ing the disease or even will permit the reduction of the sugar in 
the urine. Real improvement has been effected upon a diet 
of potatoes with plenty of butter and two or three eggs daily 
or meat broth. Von Noorden's oatmeal diet is a favorite, 
when a restricted protein-fat diet palls upon a patient or diacetic 
acid is demonstrated in the urine. It consists in taking a por- 
ridge made of oatmeal (about 200 to 250 grams), 100 grams of 
butter, and two or three eggs or equivalent of vegetable protein. 1 

1 Von Noorden prepares oatmeal for diabetics as follows; 250 grams of oatmeal are 
cooked for several hours in water, to which a little salt is added: 100 grams of butter are 
added while the porridge is cooking: 100 grams of egg albumen is added when the por- 
ridge is cool or the same amount of vegetable albumen while it is cooking. The whole 
of this is eaten in divided portions about every two hours during a day. 



DIABETES. 



413 



These ingredients are to be cooked together. I find that pa- 
tients generally prefer to take their oatmeal and eggs separately. 
With the former I permit cream to be eaten. The oatmeal regi- 
men should be continued for three or four days consecutively 
and then should be interrupted for one or two days by a diet 
containing about 30 grams of meat and various green vegetables 
which contain no starch or almost none. Then the oatmeal 
regimen should be repeated and for two weeks or more the 
green vegetable and oatmeal diets should be alternated. In 
this way surprising reductions in the amount of sugar in the 
urine, even its disappearance has been effected. However, 
the regimen is so monotonous that it cannot be maintained 
much longer than two weeks at a time but it can be returned to 
from time to time. 

A diet of a limited amount of protein, fat, and rice has also 
been found beneficial. 

Potatoes as they contain a large percentage of water can be 
eaten in larger amounts than bread, and therefore are often 
more satisfying in the chronic mild cases for which some car- 
bohydrates are permissible. 

The following vegetables may be eaten by diabetics: cress, 
cabbage, lettuce, sprouts, endives, broccoli, spinach, chicory, 
cucumber, mushrooms, artichokes, green French beans, 1 sauer- 
kraut, cauliflower, dandelion, sorrel, asparagus, onions, leeks, 
tomatoes. 

The following table shows the relative percentage of the 
important constituents of the commonest vegetables: 

Protein Fat Carbohydrate 

Lettuce 1.4 ° • 3 2 • 2 

Sprouts 4-8 0.5 6.2 

Cabbage 1.9 0.2 4-9 

Spinach 3 • ° ° • 5 3-8 

Cucumber 1 . o o . 1 2 . J 

Mushrooms 3.6 0.3 6.8 

String-beans 2 2.7 0.1 6.6 

1 Kleen says that string-beans contain several per cent, of sugar and starch when the 
seeds are developed; they should be eaten when green. Sauer-kraut, when well fermented 
contains only a trace of sugar. Celery contains 10 per cent, of sugar, and must be forbidden 
when diabetics are on a strict diet; some clinicans permit it at other times. 

2 When green the percentage of carbohydrate is much less. 



414 DISORDERS OF NUTRITION. 

Protein Fat Carbohydrate 

Cauliflower 0.5 0.3 4.5 

Asparagus 1.8 0.2 2.6 

Onions 2.7 6.3 6.5 

Tomatoes 1.2 0.3 4.1 

Jerusalem artichokes 1 .... 2.0 0.1 I 5- 2 

Radishes 1.2 0.1 3.8 

Celery 4.6 0.8 10. o 

Parsley 3.7 0.7 7.4 

Carrot 1.0 0.2 9.4 

Turnip 2.1 0.1 1 1 . 7 

Potato 1.8 0.2 20.6 

Sweet potato 1.3 0.3 23.0 

Beans (dried) 24.3 1.6 49.0 

Peas (dried) 22.8 1.8 52.4 

Roots and tubers, such as potatoes, carrots, and turnips, as 
well as beans, peas, and Lima beans, must be forbidden to 
diabetics, because of the large amount of carbohydrates that 
they contain. When the diet is relaxed, or the case is a mild 
one, a potato is often permitted. It is always craved when 
long forbidden, and is undoubtedly much less harmful than 
the same weight of bread. 

The following table showing the composition of fruits is the 
best guide to their selection for diabetics: 





Protein 


Fat 


Carbohydrate 


Cranberries 


O.I 






1.5 


Strawberries 


0.9 






3 . to 4.0 


Raspberries 


A. 






5-3 
5-5 
5-9 
7.2 


Oranges 

Blueberries 


0.4 

0.8 










Almonds 


24. 2 


53 


7 


Walnuts 


16.4 


69. 


2 


7-9 


Peanuts 


28.2 


46. 


4 


8.0 


Gooseberries 


0.5 






8.4 


Plums 


0.4 






8.2 


Hazelnuts 


15.6 


66. 


5 


9.0 


Peaches 


0.6 






11 -5 


Pears 


0.4 






12 .0 


Cherries 


0.7 






12 .0 


Grapes 


0.6 






16.3 


Bananas 


1-9 





.6 


23.0 



1 Inulin, levulose, and gum compose the carbohydrates in Jerusalem artichokes. They 
are therefore an appropriate food in diabetes. 



DIABETES. 4 1 5 

Protein Fat Corbohydrate 

Chestnuts 5.5 1.4 38 .3 

Fi g s 50 45-3 

Pears (dried) 2.0 0.3 58.8 

Apples (dried) 1.3 0.8 59-8 

Raisins 2.4 0.6 62.0 

Prunes 2.2 0.5 62.3 

The first half of these contain a percentage of carbohydrate 
which makes it permissible to allow a prescribed amount of 
them to a mild case of diabetes. Ebstein recommends peaches 
and apricots. All fruits should be forbidden to those who are 
on a strict diet. Dried fruit, preserved fruits, and most dishes 
flavored with or garnished with fruit must at all times be 
forbidden. A measured quantity of nuts (except chestnuts) 
may be allowed in mild cases. 

Diabetic patients may be permitted to drink water as freely 
as they desire. Tea and coffee may also be allowed, providing 
no sugar is used in them and but little cream. Cocoa and 
chocolate contain not only a considerable amount of carbohy- 
drate, but, as usually marketed, an additional percentage of 
sugar. The frequent or constant use of alcoholic beverages 
is likewise undesirable, for they irritate both the liver and the 
kidneys, which are unusually active in diabetics. Brandy 
and whiskey contain no sugar, and several wines, such as Swiss 
wine, Rhine wine, Burgundy, Bordeaux, and Austrian (red), 
contain but little. Wines should not be used to flavor foods 
unless in the smallest quantities. Lemonade can be made with 
saccharin, and is unobjectionable. 

Several of the European spas are famous as resorts for 
diabetics. The best known of them are Carlsbad, Neuenahr, 
and Vichy. It is doubtful if the waters in themselves influence 
diabetes. They may affect favorably concomitant digestive 
disorders and toxemia. That a short sojourn at these spas 
is of advantage, is too well known to require a new demonstra- 
tion. Benefit, however, is derived from a change of life, from 
an outdoor life, from exercise, and from a regulated diet; all of 
which are incidental to residence at such a place. 

Kleen, of Carlsbad, most frankly and justly says: "As for 
glycosuria, Carlsbad and Vichy water, and, doubtless, also 
Neuenahr water, in the moderate and rational amounts recom- 



41 6 DISORDERS OF NUTRITION. 

mended at present, which scarcely ever go beyond a liter a day, 
have no appreciable influence, or at least one that is extremely 
slight and uncertain. " 

Mental depression and excitement are very harmful for those 
who have diabetes. Whenever possible, patients should be 
freed from business care, family troubles, or a life of excitement. 
During the last few years of wide-spread financial embarrass- 
ment I have frequently been able to trace the effect of sorrow 
and anxiety in the increasing physical troubles of my diabetic 
patients. Sexual excess should also be avoided. 

The skin should be kept active by baths and friction, and the 
patient carefully protected by woolen or silken underwear from 
sudden changes of temperature. Regular exercise and, if 
possible, outdoor exercise should be taken to insure deep 
breathing, good oxygenation of the blood, and vigorous 
metabolism. 

When a patient belonging to the first or second groups of 
diabetics first comes under treatment I give him usually the 
following directions: Eat and drink only the articles named 
below. Those in italics are especially recommended. Drink 
water as desired, tea and coffee with cream, vichy, or appolinaris. 
Bouillon, beef-tea, chicken-broth. Breads, wheat (stale) , graham. 
Potatoes (boiled, baked), cabbage, (boiled, raw), sauer kraut 
cauliflower, beans (string or wax), tomatoes (raw or stewed), 
vegetable marrow, spinach, lettuce, asparagus, cucumbers, onions, 
radishes, celery, (raw or boiled). Gooseberries, currants, grape- 
fruits, oranges. Cheese (fresh dairy, edam, cream), butter, olive 
oil. Eggs (soft-cooked, boiled, poached or fried). Meat, beef 
(steak, roast), lamb (chop, roast), mutton, sweet breads, chicken, 
pigeon, turkey, quail, partridge, ham (cold boiled) , bacon (hard 
fried). Fish, codfish, whitefish, perch, trout, shad, oysters, clams, 
lobsters, crabs, shrimp, salmon, mackerel, sardines, caviar. 
Mushrooms. Eat slowly, small portions and only at meal- 
times. Do not eat sugar or food sweetened with it. Use 
saccharine if you desire to sweeten anything. Do not eat 
more than one thin slice of bread at each meal or if you prefer 
substitute one medium sized baked or boiled potato forthe 
bread. 

After three or four days I cut from this list the bread; in a 



RHEUMATOID ARTHRITIS. 



417 



day or two more the potato and in one or two days more the raw 
cabbage, cauliflower, beans, onion, raw tomatoes, radish, celery, 
fruit, oysters and clams, and limit the amount of meat eaten to 
a small portion. If possible, this closely restricted diet is 
adhered to for one or two weeks, during most of which time sugar 
will have been absent from the urine. Moreover, during this 
time a readjustment often takes place which permits a normal 
metabolism of a limited amount of starch. A variable period 
of two to six weeks may follow when a more liberal diet is 
permissible (similar to that outlined above or often with only 
one kind of any food rich in starch, such as potatoes or wheat- 
bread or squash or carrots). However, it is best at least once 
a week during it to prescribe a day when only a minimum 
amount of meat or eggs and green vegetables are permitted. 
This may be outlined as follows: tea, coffee, boullions, spinach, 
lettuce, asparagus, cooked cabbage, sea-kale, endive, water 
cress, cucumber, two eggs and a small portion of chicken or 
fish, butter and olive oil. In the severe cases, periods of closely 
restricted diet must be alternated with the more liberal diet. 
In the mildest cases a modicum of starch may be permitted 
over long periods but the urine should be examined frequently 
and if sugar reappears in it, a period of restricted diet should be 
instituted. 

In mild cases at first for many months at a time it is easy to 
exclude sugar from the urine by very moderate dietetic manage- 
ment but as time goes by, when it appears, it gradually be- 
comes more and more difficult to eliminate it from the urine 
and more and more difficult to keep it from reappearing. This 
condition is usually developed several years, often ten or more, 
after the disease began. Usually by this time traces of albumen 
appear in the urine either from time to time or continuously and 
hyalin and a few granular casts are also discoverable. Blood 
tension is higher and frequently the heart is somewhat hyper- 
trophied. Under these circumstances it is safest to permit the 
eating of a modicum of starchy food most of the time, but if the 
sugar at any time becomes considerable, it is well to prescribe 
a period of nonstarch and sugar-bearing foods to be followed 
by one of the oatmeal or potato diet or an exclusive milk diet. 
Thus at first affecting a reduction of glycosuria and later resting 
27 



418 DISORDERS OF NUTRITION. 

the kidneys from excessive nitrogen elimination. The care- 
fully prescribed mixed diet can usually be resumed with safety 
for a time. The total quantity of food eaten at this time must 
be limited carefully. The bowels must be kept open, much 
exercise must be avoided and everything possible done to 
lessen arterial tension and to prevent any sudden heart or 
vascular strain. During the periods when the diet is limited 
to meat, eggs, green vegetables, butter and olive-oil, alkalies 
and alkaline waters must be given regularly. 

When a strict diet must be maintained, the cook should 
endeavor to furnish by skilful preparation a large variety of 
dishes from the limited number of articles that the patient is 
allowed to use. 

It must be remembered also that several of the vegetables 
usually eaten raw which are permissible at this time can also 
be cooked and thereby provide a more varied menu. Moreover, 
some of them contain less starch when cooked. This is notably 
true of cabbage, sea-kale, vegetable marrow, tomatoes, lettuce, 
celery, and cucumbers. All of which may be permitted when 
cooked though some of them cannot be allowed when eaten 
raw. 

When patients are maintaining a 'fast day,' it is best to 
prescribe only two meals a day — one at breakfast-time and one 
about six in the evening. At noon an egg-lemonade made with 
saccharin may be taken if it is desired. The amount of food 
eaten at the two meals should be limited. 

RHEUMATOID ARTHRITIS 

Although a patient who has suffered long from chronic rheu- 
matism, whose joints have become much enlarged and almost 
immobile, and whose muscles consequently have greatly atro- 
phied, presents to the careless observer almost precisely the 
same appearance as one suffering from rheumatoid arthritis, 
the two maladies are distinct, and require very different dietetic 
and medicinal treatment. Those who are suffering from 
rheumatoid arthritis should be fed as generously as possible. 
Digestion and appetite being usually good during the earlier 
stages of the disease, they should be allowed to eat heartily 



GOUT. 



*i$ 



of all simple foods. Later, when the appetite diminishes, 
although digestion may remain good, foods should be crowded 
upon them, especially such foods as contribute to maintain a 
good degree of flesh. Farinaceous, cereal foods, fats, and oils 
are particularly to be commended. When it is well tolerated, 
cod-liver oil is of considerable value to such patients. 

When, as happens sooner or later in most cases, digestion is 
disturbed because of lack of exercise, and because of generous 
feeding, foods must be carefully adapted to the capacity of the 
digestive organs. In these cases, as in cases of chronic rheuma- 
tism, water should be given freely. 

As much exercise, either passive or active, as the patient can 
take without great pain and discomfort should be prescribed. 
Every endeavor should be made to maintain the strength of the 
muscles that are inclined to atrophy. 

If at all possible, these patients should be treated in climates 
where they are not exposed to dampness, and where they will 
have a maximum amount of sunshine. Certain spas, especially 
those possessing thermal and sulphurous waters, have acquired 
considerable reputation as resorts for patients with rheumatoid 
arthritis. 

GOUT AND GOUTINESS 

Definition and Causes 

Gout is a well-defined disease described clearly by characteris- 
tic symptoms. Goutiness is a condition which predisposes to 
gout and often manifests itself by variable symptoms. It is 
frequently also called 'gouty diathesis' or a 'lithemic state.' 
Gout as a constitutional disease is due to a fault of nutrition. 

Its exact cause and the physiological perversions or changes 
which constitute gout and the gouty state are unknown. The 
symptoms of the disease are well known as are many of its 
complications. It is known that in this disease uric acid com- 
pounds exist in the blood in larger quantities than is normal 
and that often certain of these are deposited in the tissi: 
joints, of the kidneys, of the ear and other structures. Rut 
it has been demonstrated also that uric acid will not cause the 
phenomena of gout or goutiness and that it may exist for long 
periods of time in large quantities in the blood in other 



420 DISORDERS OF NUTRITION. 

for instance, leukemia, without producing symptoms which 
even suggest gout. The excess of uric acid in the blood may be 
due to overproduction, to imperfect elimination or imperfect 
destruction and conversion into substances more easily elimi- 
nated. There is not adequate evidence that too much uric 
acid is formed. It is probable that there is imperfect elimina- 
tion and conversion of uric acid into compounds which are 
readily eliminable. However, the latter is still a matter of con- 
troversy. That purin bodies occur in different tissues in 
different forms and in different relative proportions is well 
established. Furthermore it is established that various cell- 
ferments have the power of modifying the various purin bodies 
and transforming them into simpler ones and that uric acid 
itself can be converted by oxidase in the liver and in other 
tissues into urea. It may be that a ferment of this kind is no 
longer formed or becomes inactive in gout, thus causing an 
excess of uric acid to accumulate in the blood. However, this 
is theory with few facts to support it. It is known, nevertheless, 
that alcohol given with a definite quantity of purin bodies or 
nuclein will cause greater elimination of uric acid by the kidneys 
than occurs when no alcohol is given or when alcohol and a 
smaller quantity of purin bodies are given. It therefore seems 
probable that alcohol inhibits the transformation of uric acid 
into urea by oxidase. 

Uric acid is derived from the nucleins of foods and hypoxan- 
thin of muscle used as food and from the same substances in 
the living body set free by the disintegration of nuclei and 
by the activity or wear of muscles. It has therefore an ex- 
ogenous and endogenous origin. It is not known certainly 
whether in gout it is derived more from food or from the 
tissues of the gouty. 

Why urates are deposited in certain tissues in gout is not 
known. It is not because urates exist in the blood in excessive 
quantities. There is doubtless a change in the tissues involved 
which leads to their deposition in them. Various theories have 
been propounded to account for this phenomenon but no one 
can be regarded as an established explanation. 

Some believe that uric acid in excess in the blood of the gouty 
causes arteriosclerosis and interstitial nephritis. However as 



GOUT 421 

it does not do so when injected into the blood in large quantities 
nor in other diseases in which it exists in the blood in excess 
this belief is not tenable. It is more probable that the blood 
vessels, the heart and the kidneys are effected as a part of the 
disease and not by uric acid which is in a sense a by-product of 
the disease very much as sugar is in diabetes. 

These explanations make it evident that as yet enough is no; 
known to establish diatetic or other treatment upon a scientific- 
basis. Treatment must still be empiric or guided by theories. 

An attack of gout is recognized by painful swelling of certain . 
sometimes numerous, joints. The first attacks of gout are 
usually limited to the larger joint of the great toe. The joint 
which is affected becomes swollen, extremely painful, slightly 
reddened, and often exquisitely tender. If a joint is repeatedly 
attacked, or the disease becomes subacute or chronic, it is often 
permanently injured by the deposition of sodium urate in the 
tissues. Such deposits also occur quite frequently along the 
sheaths of tendons and in other places where fibrous tissue is 
abundant. Lack of appetite and disturbed digestion are in 
most instances associated with these local symptoms. 

Goutiness often shows itself by disturbances of the nervous 
system. Mental depression is a noticeable feature in some 
instances ; in others, periodical headaches. In a third group the 
symptoms usually described as those of biliousness are ch 
teristic of an attack. In still other cases the anatomic changes 
and symptoms of arteriosclerosis are indicative of the uric acid 
diathesis. Contracted kidney is often developed in these t 

Some patients in the lithemic state tend to develop obesity 
early in life, which frequently leads to fatty infiltration of the 
heart and causes a fatal weakness of that organ. In < 
cases the liver becomes enlarged and degenerated. Not in- 
frequently, and especially in women who are inelined to a 
gouty condition, Heberden's nodes develop about the finger- 
joints. 

Those who are hereditarily inclined to goutiness are often 
plagued with skin eruptions in early life; as, for instance. 
successive attacks of eczema. During youth, early manhood 
and womanhood, periodical attacks of migraine frequently 
take the place of the skin eruptions of the earlier years of life. 



422 DISORDERS OF NUTRITION. 

and, later still, renal and hepatic colics become common in these 
patients. In a few a rebellious bronchitis develops which 
responds best to treatment for gout. 

While there is no doubt the disease is generally an inherited 
one, it is equally certain that it may be acquired. The same sys- 
temic conditions that are most frequently the immediate cause of 
outbreaks of acute gout in those who have inherited a tendency 
to it are the causes of its acquisition by others. Long-con- 
tinued use of food in too large quantities or too rich in quality 
is a common cause of the ailment. Prolonged constipation, 
and the indigestion and torpidity of the liver associated with it, 
are common causes. A sedentary life and too little exercise are 
particularly apt to produce the constipation and the indigestion 
which predispose to it. Long-continued or intense mental 
depression also may bring on acute attacks. While oftenest 
too rich and too much food and too little exercise provoke gout, 
occasionally acute attacks of the disease develop in those who 
are prone to it because they eat too little food or take an ex- 
cessive amount of exercise. 

Treatment 

It is generally believed that food rich in nuclein and purin 
bodies should not be given to the gouty or should be given only 
in small quantities that it may not increase the production of 
uric acid. It is also believed that its conversion into urea 
should not be hindered and that if possible its elimination 
should be helped. 

There is little that can be done to shorten the painful attacks 
of acute gout, though the discomfort attending them may be 
lessened by suitable treatment. A great deal more can be 
accomplished toward preventing a recurrence of acute attacks 
by instituting a proper regimen. 

It is impossible to remove the inherited fault of nutrition, but 
it may be possible to retard the development of the symptoms. 
Temperance must be taught as the cardinal rule for the conduct 
of life. Those who inherit a tendency to gout should, even in 
early childhood, learn the necessity of abstemiousness. Glut- 
tony, even in its most moderate form, must be avoided. A 
fairly varied diet may be permitted provided it include foods 



GOUT 423 

which are simply prepared and easily digested, but they should 
be taken only in moderate quantities. 

When the gouty state is fairly established, not only must 
temperance be insisted upon, but certain articles of diet must 
be forbidden. These are sweets, confections of all kinds, fats, 
articles cooked with much fat, game, and the richer meats, 
especially when dressed with rich sauces. Those vegetables 
which are rich in oxalates ought also to be avoided by the gouty. 

Gouty people should use as little sugar as possible. Such 
vegetables as rhubarb, tomatoes, radishes, spinach, cabbage, 
and, if they cause flatulence, baked beans, should be avoided. 

The foods which these patients eat should be fairly varied, 
and the diet well balanced, containing the necessary proportion 
of albumin, carbohydrates, and fats; and the individual articles 
of food should be prepared so as to be most easily digested. 
Meat may be eaten moderately, but green vegetables and some 
fats, as well as cereal foods, may be taken generously. In 
prescribing a diet for those who are gouty, care should be taken 
not to restrict it so as to lessen the vitality of the individual. 
It has been urged that a milk diet is the best for the prevention 
of outbreaks of gout in those disposed to them; but milk, unless 
used in excessively large quantities, is not sufficiently nutritious ; 
and while it may well be used as an important element of food, 
it should not be the exclusive diet of the gouty. 

Soups, which may usually be taken in small amounts by 
those inclined to this ailment, should be forbidden when the 
symptoms of goutiness are clearly manifested. Whenever 
they are used, they should be entirely free from fats, and pre- 
ferably should not be made with a meat stock. Eggs, oysters, 
and clams may also be eaten, but lobsters, crabs, and shrimps 
are not to be recommended. Most fish can be eaten without 
harm; for example, bluefish, whitensh, perch, shad, bass, and 
trout; but the fish richer in fats and those that are smoked and 
salted, such as salmon, mackerel, halibut, and cod, should not 
be used. Rich sauces should also be avoided. Meat should 
be eaten not oftener than once daily, and generally roasted or 
broiled. The meats most to be avoided are pork, veal, game, 
and meat which is salted and smoked. Fat should be used in 
very moderate amounts. Butter can be used with a w 



424 DISORDERS OF NUTRITION. 

able degree of freedom, and cream moderately. It will be 
noticed that the amount of protein in the flesh foods which 
are permitted does not differ much from that in those forbidden. 
In choosing between different kinds of meat one must be 
guided mainly by their digestibility. Boiled meats contain 
less extractives than fried, broiled or meats cooked in other 
ways and are the best especially for those whose kidneys are 
defective. Such carbohydrate foods as bread, rice, sago, 
tapioca, oatmeal, and cracked wheat may be eaten generously, 
but pastries, hot breads, pancakes, and other articles of a similar 
kind, which are liable to form doughy masses in the stomach 
during the period of gastric digestion, should be avoided. 

The following green vegetables may be used freely: peas, 
string-beans, corn, potatoes, turnips, carrots, parsnips, celery 
and celery plant, cauliflower, artichokes, broccoli, salads, 
cucumbers and egg-plant. Of the fruits, the following are 
best adapted to the use of gouty patients: pears, apples, rasp- 
berries, blueberries, blackberries, and oranges; but grapes, 
bananas, prunes, strawberries, and melons are not so whole- 
some. Pickles and condiments are to be avoided at all times. 

Eating between meals should not be permitted. Gouty 
patients should be taught to eat slowly and to masticate their 
food carefully. 

Tea and coffee, if in small amounts and with no, or very little, 
sugar, may be used by many who are predisposed to gout so 
long as they have no active symptoms of the disease or of in- 
digestion; but if digestion is slow, or there are other symptoms 
of gout or goutiness, these beverages should not be taken. 

It is universally admitted that alcoholic beverages of all kinds 
are harmful. Their use not infrequently, even in very small 
amounts, will provoke attacks of gout. The degree of tolerance 
of alcoholic beverages by those who are gouty is, of course, very 
variable. It is generally believed, however, that the fermented 
beverages are more harmful than the distilled. 

It is not necessary, in order to provoke gout, that these 
beverages should be taken to the point of intoxication. Indeed, 
it is rare that the drunkard develops symptoms of the disease. 
Most frequently it manifests itself in those who are habitual 
users of alcoholic beverages in moderate amounts. Ale, beer, 



GOUT. 425 

and the sweet and the heavy wines are the beverages which 
are most apt to provoke the trouble. Of wines, the dry white 
wines and old Bordeaux have been found the least harmful. 

Patients who are gouty should be instructed to drink water 
freely, as by its use the kidneys can be made to act freely and 
thus wash out much of the waste matter that might otherwise 
accumulate in the system. They should drink from five to 
eight glasses of good pure water daily. Often, however, these 
patients are taught to drink too much fluid for when their hearts 
grow weak or arteriosclerosis is extensive large quantities 
unduly tax the cardio-vascular system. 

There have been many spring-waters recommended as 
preventives of gout. It is probable that large quantities of 
water do more good by the physical presence of fluid in the 
blood-vessels and tissues than the various mineral ingredients 
which spring- water may from time to time contain. There are 
three varieties of spring-waters especially recommended for 
gout: First, those which are particularly pure and contain a 
minimum amount of mineral matter. Without doubt, their 
effect is purely a physical one. The second group includes the 
alkaline waters of which Vichy is a type. The alkalies, intro- 
duced into the blood well diluted, do seem to stimulate normal 
nutritive changes in the tissues of the body. The alkaline 
waters also have a beneficial effect upon the contents of the 
stomach, which are usually acid because of abnormal fermenta- 
tion. The third group of waters often used by those who are 
suffering from gout are the alkaline purgative waters of which 
Carlsbad is a type. This kind is particularly good for those who 
are fleshy and inclined to constipation. 

At all times those modifications of the diet must be remem- 
bered which the common gastric, hepatic, renal and cardio- 
vascular complications necessitates. Indeed one or more of 
these complications may govern the diet completely. In 
almost every case indigestion in one of its forms will necessitate 
changes and frequent variations in the diet of individual 
patients. These changes have been discussed already in the 
chapters devoted gastric, renal and cardio-vascular diseases. 

While it is absolutely essential, in order to prevent the 
symptoms of goutiness and the recurring attacks of gout, that 



426 DISORDERS OF NUTRITION 

the food and drink of patients should be carefully regulated, 
it is equally necessary that exercise be taken regularly in at 
least moderate amounts in order to maintain normal nutritive 
changes in the tissues of the body and to correct the metabolic 
vice that is characteristic of goutiness. Although, occasionally, 
excessive exercise will cause very rapid wasting of the muscular 
tissues and consequent accumulation in the blood of a large 
amount of effete matter, which is provocative of attacks of 
gout, it is much more frequently the case that lack of sufficient 
exercise to maintain a perfect distribution of the fluids of the 
body, and to stimulate the necessary metabolic processes of 
the tissues, is the cause of the disease. Therefore it becomes 
necessary early to educate those who are disposed to gout to 
take daily a sufficient amount of active exercise to promote 
healthful nutritive changes in the tissues. These changes will 
take place only when sufficient exercise is taken to maintain a 
fairly firm condition of the muscles and to prevent the accumu- 
lation of any considerable amount of fat about the viscera. 
It is not only necessary to promote free elimination of waste 
matter by the kidneys, but it is essential that both by exercise 
and bathing, the skin be kept active, and deep breathing, and 
thorough oxygenation of the blood be maintained. It is also 
important that the intestinal tract be thoroughly and regularly 
emptied. Frequently the daily bowel movement is not suffi- 
cient, and it must be made more copious. 

During the acute attacks of gout we may palliate by medici- 
nal treatment, or by hot baths, or by heat applied locally to 
the inflamed joints; but, after all, Cullen's aphorism that "the 
treatment of gout must consist chiefly in patience and flannels" 
is as true to-day as when it was first spoken. 



INDEX 



Absinthe, 145 

Absorption of alcohol, 137; of carbohydrates, 
32; of fats, 25; of milk, 77; of peptone, 20; 
of water, 9; rectal, 211 

Achlorhydria, 275. See Gastritis, Chronic. 

Acid albumin in digestion, 19 

Acid, hydrochloric, in digestion, 18 

Acid, lactic, in cholera, 225 

Acid, tannic, in cholera, 226 

Acids at the end of meals not harmful, 18; 
before meals, harmful effects of, 18; 
beverages in cholera, 224, 225, 226; in 
wine, 147; injections in cholera, 226 

Acne, 379; causes of, 379; fats to be re- 
stricted, 25; from gastro-intestinal fer- 
mentation, 379; from overeating, 201; 
general treatment, 379; simple diet, 379; 
Rosacea, 378; causes, 378; causes, 
dietetic, 378; from alcohol, 378 

Adult life, amount of food needed in, 40 

Adulteration of food, 202 

Aerated waters, addition of, to milk, 77 

Agassiz, 154 

Age of children, variation in diet according 
to, 196. See also Children. 

Aged person, diet for, 158 

Albuminuria, 348; causes of, 348; fatigue 
causative, 349; foods to be avoided, 349; 
gastro-intestinal indigestion causative, 
349; milk in, 350; Cyclic, 349; In 
diphtheria, 251; in erysipelas, 234; in 
febrile maladies, 349; in influenza, 247; 
in pneumonia, 321; in scarlet fever, 231; 
in smallpox, 250; in yellow fever, 223; 
Intermittent, 349. See also Kidneys, 
Diseases of; and Nephritis. 

Alcohol, absorption of, 137; as a carbo- 
hydrate sparer, 139; as a cardiac depress- 
or, 138; as a cardiac stimulant, 138; as a 
fat sparer, 139; as a food, 138; as an anti- 
pyretic, 141; as an antiseptic, 143; as a 
medicine, 144; as a protoplasmic poison, 
136; as a stimulant to digestion, 
136. Effects of, on brain, 141; on diges- 
tion, 136; on heart and blood-vessels, 137; 
on kidneys, 143; on liver, 143; on mental 
processes, 142; on metabolism, 141; on 
moral perception, 142; on muscular 
energy, 141; on nervous system, 142; 

427 



on oxidation, 139; on spinal cord, 142; 
on temperature, 140; on vasomotor 
center, 142; pathogenic, 142; physiologric, 
136. Food value of, 140. Habitual use 
of, 138, 142. Percentage in malt liquors, 
146; in spirits, 144, 145; in wine, 147. 
Susceptibility to, 143. Unnecessary in 
health, 136; in sickness, 135. 

Alcoholic beverages, 135, 144; classification 
of, 144; ale, 145; beer, 145; brandy, 144; 
cider, 148; gin, 145; liqueurs and bitters, 
145; porter, 145; rum, 145; spirits, 144; 
stout, 145; whisky, 144; wine, 146; wines, 
artificial, 148; wines, sparkling, 148. 
Effects of, 136. Use of, in typhoid fever, 
220; in tuberculosis, 242. See also under 
the various diseases. 

Alcoholic fermentation of sugars, 1 1 1 

Ale, 145; bitter, 146; m'ld, 146 

Aleuronat, 209 

Algid state in cholera, 228 

Alimentation, rectal, 211. See F« 
Rectal. 

Alkali albumins, production of, 19 

Alloxuremic disturbances from alcohol, 142 

Almond cakes, 411 

Amido-acids, production of, 19 

Anasarca in chronic heart disease, 339 

Anemia, from insufficient meat, 201; in 
heart disease. 338; kumiss cure, 82. 
Pernicious, progressive, 294 ; arsenical 
preparations in, 296; causes of, 295-6; 
characterization of, 294; conditions pre- 
disposing to, 295; diet for. 294 ; di| 
agents, 297; intestinal antiseptics, 296; 
lavage, 297; milk, 297; nutritive enemata. 
297; predigested foods, 297; primary, 294; 
rest in, 297; secondary, 288; vomiting in. 
treatment of, 296; water in. 297; Simple, 
288; causes of. 288; change of climate, a88; 
diet for, 290; exercise, 289 

Aneurysm of the aorta. 341; diet 1 
electrolysis, 343; fluids, I 
gelatin solution, hypodcrmicaUy. inter 
nally and intravenously. \;\. Tufncll's 
regimen, 3.4: . Valsalva*! regimen. 

Angina pectoris, 340; abstemiousness in 
diet, 340; dietetic ba dlcatfcm a, *4' 
cise, regulation of, 34 ' i fluids, moderation 
in, 340 



428 



INDEX. 



Animal fats in dietetic use, 2 7 

Animal food. See Food, Animal. 

Animal foods, 6, 68; composition and fuel 
value of various kinds, 101-106; digesti- 
bility of various kinds, 99. See also 
Foods, Animal. 

Animal proteids, 18 

Anisette, 145 

Antipeptone, production of, 19; proteins 
absorbed as, 19 

Antiscorbutics, fruits as, 120; green vege- 
tables as, 118 

Antiseptic, alcohol as an, 143 

Aorta, aneurysm of, 341. See Aneurysm. 

Apenta water, 17 

Appendicitis, 310; liquid foods, 310; vomit- 
ing in, 310; withholding of foods, 311. 
After operation, foods to be avoided, 311 

Appetite untrustworthy as guide to diet in 
sickness, 207 

Apples, 120, 122; iron content of, 293 

Appolinaris, 15, 274 

Armour's wine of peptone, 209 

Army and navy rations, 43 

Arrow- root, 116 

Arterioles, effect of alcohol on, 137 

Arteriosclerosis, 343; causes of, 343; from 
high living, 155. Diet in, 344; food to be 
avoided, 344; milk, 344; restriction of 
meat, 344. Treatment of, 344; dietetic 
and hygienic, 343. With heart disease, 
diet for, 336 

Arthritis, rheumatoid, 417; diet, generous, 
simple, 418; farinaceous foods, 418; fats 
and oils, 418; water, 418. Muscular 
atrophy, 418. Treatment, climate and 
spa, 418; hygienic, 418 

Ascites, 323; dietetic treatment, 323 

Asparagus, 119; canned, tin poisoning from, 
203 

Asthma, 329; diet for, 329-330; indigestion 
and constipation as causes, 329; idiosyn- 
crasies in, 329 

Atheroma with heart disease, diet for, 336 

Athletes in training, diet for, 151 ; sugar for, 
152 

Atwater, 42, 45, 50, 65, 84, 153, 199 

Atwater and Bryant, 153 

B 

Babcock's milk tester, 177 

Bacon, 26; for children, 198 

Bacteria in stomach and intestine, harmful 
effects of, 2 1 

Bacterial contamination of milk, 72; fer- 
mentation in alimentary tract, 31; fer- 
mentation, results of, 32 

Baden Baden, 17 



Banana, 120; meal, 121 

Banting, 386, 387 

Barie, 226 

Barley jelly, preparation of, 194; meal, 112, 

114; Robinson's, 194; water, 77; water as 

a diluent for milk, 193 
Bauer, 242 
Baurer, 186 
Brie cheese, 85 
Beans, composition of, 117; in beri-beri, 

402; flatulence from, 117; iron content of 

293; peas and, 117 
Bedford Springs, 17 
Bedt, 393 
Beef, chemical composition and fuel value 

of various cuts, 101, 102; extracts, 94; 

iron content of, 293; juice, commercial, 

95; juice, home-made, 94; juice, nutritive 

value of, 96; juice, raw, for rectal feeding, 

211; juices, composition of, 94; meal, 

Mosquera's, 96 
Beer and ales, 14s 
Beer as a soporific, 146; bitter, 146; brewing 

of, 145; effects of, on digestion, 146; mild, 

146 
Beets, composition of, 116 
Benedictine, 145 
Beneke, 286 
Beri-beri, 400; causes, 400; distribution, 

400; in infancy, 402; treatment, 401 
Beverages, 129; acidulated in cholera, 224- 

226; alcoholic, 135, 144; cocoa, 133; 

coffee, 131; tea, 129 
Beverages for young children, 196 
Bile in fat digestion, 25 
Biliousness from eggs, 90; from meat diet 

without exercise, 22 
Bitters, liqueurs and, 14s; liqueurs and, 

composition of, 145 
Blood, diseases of, 288 ; anemia, prenicious, 

294; anemia, simple, 288; chlorosis, 290; 

leukemia, 297; pseudoleukemia, 300. 

Diet in, 288 
Blue Lick Springs, 17 
Body, animal, chemical elements of, 3; 

animal, chemical composition of, table 

showing, 4; fat and fat food, uses of, 24; 

fat, uses of, 24; fat, sources of, 24 
Boric acid in foods, effect of, 202 
Bouchard, 386, 389, 397 
Bouillons, 93 
Brain and nervous system, degenerative 

changes in, from alcohol, 142; vessels of, 

action of alcohol on, 141, 142 
Brain-workers, diet for, 154 
Bran, 112 

Brandy, 144; effects of, on digestion, 136 
Bread, 113 ; absorbability of, 1 14; aleuronat. 



INDEX. 



429 



209; cocoanut, 411; for diabetics, 411; 
gluten, 411; Graham, 411; making, 113; 
peanut, 411; percentages of sugar and 
carbohydrate in various kinds, 411; 
pulled, 113; rye, 410; soya, 411; stale, 
digestibility of, 113; toast, 113; wheat, 
411; white, 113; whole wheat, 114; 
zwieback, 113 

Brehmer, 244 

Bromine, 16 

Bronchial inflammation during convales- 
cence from measles, 233 

Bronchitis, capillary, and catarrhal pneu- 
monia, 327; antirheumatic treatment, 
328; classes of patients, 327; diet for, 327; 
in the aged, 327; in children, 327; in 
lithemic patients, 3 28 ; in lithemic patients, 
foods forbidden, 328; in middle life, 327; 
nutritive enemata, 327; poultices, 327. 
Convalescence, diet for, 327-8 

Bronchitis, chronic, 328; chronic dietetic 
and hygienic treatment, 328; chronic, 
climatic treatment, 329; simple acute, 
326; diet for, 327; hot fluids, 327 

Bronchopneumonia during convalescence 
from measles, 233 

Buckwheat flour, 112 

Bulkley, 377 

Bunge, 293 

Burke, 89 

Butler, 72 

Butter, 84 ; and cream, in disease of aliment- 
ary system, 27; adulteration of, 84 

Butterin, 84 

Buttermilk, 84 

Butyric acid fermentation of sugar, in 



Cabbage, 293; flatulence from, 118 
Cacao-butter, endermic feeding with, 210 
Caffein in coffee, 132; in tea, 130 
Caffeol, 132 
Calcium carbonate, source and use of, 37 

phosphate, source and use of, 37 
Calculi, hepatic, 319- (See also Gall-stones.) 
Oxalic acid, 346; alcoholic beverages, 
forbidden, 347; causes, indigestion, 346; 
vegetable foods, 346; diet for, 347; foods 
to be avoided, 347; exercise, 347; treat- 
ment, spa and climatic, 347; water, 347. 
Uric acid, 34s; alcoholic beverages for- 
bidden, 346; baths, hot, 346; causes of. 
345; diet for, 34s ; foods to be avoided, 
345; treatment, spa and climatic, 346; 
water, distilled or pure soft waters, 346; 
with indigestion, saline waters, 346. 
Urinary, from excess of lime and phos- 
phates, 37 



Calf's brain, 98 

California seltzer, 15 

Calorie, 41 

Calories required in food to sustain life, 42; 
quantity furnished by food-stuffs, 41. 
See also various Tables. 

Cancer, gastric, 284; diet for, 286; digestive 
agents, 286; duodenal digestion, 285; 
lavage, 287; liquid food, 286. Cardiac, 
285. Pyloric, 285; obstruction, Beneke's 
menu, 286-287; obstruction, diet for, 286; 
obstruction, feeding in, 286; nutritive 
enemata, 286 

Candies, digestibility of, III 

Cane-sugar, 109; digestion of, 30 

Canned meats, indigestion from, 202; canned 
vegetables, tin and lead poisoning from, 
203 

Cantani, 286 

Carbohydrate absorption, 32; absorption 
interfered with by intestinal inflamma- 
tion, 32; constituent in protein molecules, 
33; of milk, 6, 68; digestion of, ji; food, 
action of liver on, 32; milk-sugar best, for 
infants, 176 

Carbohydrates, 29; and fats as nitrogen 
savers, 40; as producers of calorics, 42; 
composition of, 29; concentrated, 210; 
digestion of, 29; percentage of, in sub- 
sistence ration, 43; (see also various 
Tables); sources of, 6, utility of, 33. 
See also Sugar and Starch. 

Cardiac depressor, alcohol as a, 138; irregu- 
larity from tea-drinking, 131; weakness of 
influenza, coffee for, 248. See also 

Carlsbad, 16, 274, 319, 346, 379, 414, 424 

Carlsbad Sprudel salts, 284, 293 

Carnrick's food, 193 

Carrots, 119; composition of, 116; digesti- 
bility of, 1 16 

Casein, 68, 76. 85. 86, 209 

Casselberry, W. E., 252 

Castle Hot Springs, 16 

Catabolism of proteid, 41 

Catarrhal jaundice, 317- B 
Catarrhal. 

Catarrhs, chronic, of the alimcntar\ 
kumiss cure, 82; chronic, of the I 
tory tract, kumiss cure, 82 

Cauliflower, 1 19 

Celery, 119 

Cellulose, 29. 107, 109 

Cerealine, 114 

Cereals, in; composition of, 112; flour from 
various, composition of, 113; foods for 
young children. 197; poisons in, 202 

Cerebrospinal meningitis. 249. See Meniit- 
. 1 . Cerebrospinal. 



43° 



INDEX. 



Chamberlain, 400, 402 

Chartreuse, 145 

Cheese, 85, 114; American dairy, 86; compo- 
sition of, 85; difficulty of digestion, 86; 
fatty acids in, 87; poisoning by, 87 

Cheeses, hard, 86; soft, 85; table showing 
composition, of various kinds of, 86 

Chemical classification of foods, 6; composi- 
tion of the animal body, tables showing, 
4; composition of various foods (see 
Tables); compounds deleterious, in food, 
202; elements of the body, 3; impurities 
in drinking-water, 12; impurities in food, 
202 

Chicken, young, slow digestion of, 98 

Chicory in coffee, 132 

Chittenden, 23, 42, 43, 57, 59, 60, 199 

Children, constipation in, treatment of, 317; 
diet for, 196; regular meal-times for, 198; 
varieties of food for, 197; variation in diet 
at different ages, 196; various ages of, 
diet for, compared with diet of adults, 196 

Chlorosis, 291; Bunge's diet for, 293, 294; 
Carlsbad salts and spring-waters as laxa- 
tives, 293; causes of, 291; chalybeate 
waters, 292; climatic and spa treatment, 
292; constipation in, 290; convalescence 
from diet for, 293; dietetic management, 
292; ferruginous preparations, 293; foods 
rich in iron, 292; impaired digestion, 290; 
inherited tendency, 291; lavage, 292; 
moderate exercise, 291; neuralgias in, 290; 
out-of-door life, 292; remission, 294; 
rest, 291; round ulcer of the stomach in, 
290; stimulating beverages, avoidance of, 
294; treatment of, 291; with dilated 
stomach, 290; with dilated stomach, with- 
holding of food, 292; with hyperchlor- 
hydria, albuminous diet, 292; with hyper- 
chlorhydria, exclusive milk diet, 293. 

Chocolate, 134; cocoa and, composition of 
various preparations, 135 

Cholelithisasis or gall-stones, 318. See 
Gall-stones. 

Cholera, 224; acid beverages, 224, 225, 226; 
acid enemata, 226; algid state, treatment 
of, 229; collapse, cause of, 227; convales- 
cence from, diet for, 228; conveyance of, 
by food, 202; conveyance of, by milk, 72; 
conveyance of, by water, 12; enteroclysis 
in, 226; feeding in, 228; gastric lavage, 
226; hypodermoclysis in, 228; infection, 
methods of, 224; intraperitoneal injection 
of hot milk in, 228; intravenous in- 
jections of water in 227; intravenous 
saline infusions in, 227; lactic acid in, 
225; prophylaxis of, 224; recovery from, 
diet for, 228; tannici acd in, 226; toxins, 



removal of, 226; treatment of, 225, 226, 
vomiting in, treatment of, 226; water, 
226; water as food, 226; water as medi- 
cine, 226; withholding food in, 225, 228 
Cholera infantum, 306; causes, 306; change 
of air, 307; cleanliness, 308; hypodermo- 
clysis, 307; indications for treatment, 307; 
lavage of stomach and colon, 307; with- 
holding of food, 307. After cessation of 
vomiting, albumen-water, 307; milk, 
diluted, 307; milk, modified, 307; milk, 
peptonized, 307; rice-water, 307 

Cholesterin, 89 

Chrome yellow as a poisonous coloring for 
cakes, 203 

Chronic diffuse nephritis, 356. See Nephritis. 

Cider, composition of, 148 

Circulatory organs, diseases of, 334. Aneu- 
rysm of the aorta, 341. Angina pectoris, 
340. Arteriosclerosis, 343. Heart, dila- 
tation of, acute, 334; dilatation of, chronic, 
335', palpitation of, 340; weak, 335; 
vavular lesions of, 335-337. Pericarditis 
and endocarditis, acute, 334 

Cirrhosis of the liver, 321. See Liver, Cir- 
rhosis of. 

Claret, composition of, 148 

Cleanliness in preparation and serving of 
food, 201 ; of utensils in infant feeding, 195 

Climate, effects of, on beef, 100 

Clover Farm Dairy, 73, 74 

Cocoa, 133; absorption of, 134; composition 
of, 133; effects of, on digestion, 134; food 
value of, 134; for convalescents, 134; 
making, 134; nibs, 134 

Cod-liver oil, digestibility of, 26; oil, ender- 
mic, feeding with 38; oil, uses of, 38 

Coff ea Arabica, 3 1 

Coffee, 131; adulteration of, 132; and tea 
substitutes, 133; as a laxative, 133; as a 
stimulant in cardiac weakness of influ- 
enza, 247; effects on digestion, 132; in 
whooping-cough, 249; making, 132; 
roasted, 132; stimulative acition of, 132 

Cohen, S. Solis, 7 

Cold storage transportation, effects on food 
supply, 48 

Colic, hepatic, 320; of infants, from excess of 
proteid in mother's milk, 173; renal, 348 

College students, dietary of, 153 

Colostrum, 171 

Coma, diabetic, 406 

Compotes, digestibility of, in 

Concentrated carbohydrates, 210; foods for 
invalids, 208; proteins, 209 

Condensed milk, 83, 191 

Congestion, passive, of kidney, 352. See 
Kidneys. 



INDEX. 



431 



Congress Springs, 17, 346 
Constipation, 312; alternating with diar- 
rhea, 313; causes, 312; chronic, 312; diet 
for, 3M-5; exercise, 313; fats in, 27; 
following diarrhea in chronic enterocolitis, 
309; from improper food; 201, 312; from 
lack of water, 10; from sour wines, 150; 
from tea-drinking, 13 1 ; fruits as laxatives, 
315; hydrotherapy, 313; laxative effect of 
water drinking in, 10, 314; foods in, 315, 
316; massage in, 313; of infants, 317; of 
infants, massage in, 317; of infants, oat- 
meal-water for, 317; of nurslings, oil for, 
317; of nurslings, treatment for, 317; pre- 
vention of, 313; treatment of, 313 

Consumption, 237. See Tuberculosis. 
Contamination of milk, 7 1 
Convalescence from acute diseases, fatty 
foods, 27; from acute gastritis, 268; from 
capillary bronchitis and catarrhal pneu- 
monia, 327; from catarrhal jaundice, 318; 
from chlorosis, 293; from cholera, 228; 
from cholera infantum, 307; from croup; 
ous pneumonia, 331; from dengue, 229; 
from diphtheria, 251; from dysentery- 
222; from enteritis, membranous, 310; 
from enterocolitis, chronic, in adults, 308, 
from enterocolitis, chronic, in infants, 309, 
310; from erysipelas, 234; from gastric 
ulcer, 283; from gastritis with hyper- 
chlorhydria, 272; from influenza, 248; 
from malaria, 236; from measles, 233; 
from meningitis, cerebrospinal, 250; from 
relapsing fever, 229; from scarlet fever, 
232; from septicemia and pyemia, 236; 
from smallpox, 231; from summer diar- 
rhea, 306; from typhoid fever, 214; from 
typhus fever, 221; from whooping-cough, 
248, 249; from yellow fever, 223 

Convalescents, cocoa for, 134 

Cooking as a preventive of parasitism from 
food, 201; effect of, on egg-albumen, 89; 
effect of, on fruit, 120; effect of, on meat, 
qo; effect of, on starchy foods, 108; in- 
fluence of, on salivary digestion, 30; of 
meats, 18; of peas and beans, 117; of 
starch, 117 

Corn, 144; iron contents of, 293 

Cornmeal, 112 

Cough, winter, chronic, treatment of, 328 

Cow's milk. See Milk, Cow's 

Crab meat, indigestibility of, 97; poison in, 
202 

Crab Orchard, 17 

Cream, 26, 83; and whey mixtures, 198 

Creme de Menthe, 145 

Crustaceans, composition and fuel value of 
various kinds, 106 



Cucumber salad, 119 

Custards, 90 

Cystitis from beer, 146 



Dates, 120 

Davis, N. S., 140, 144 
D£bove, 239, 241 

Degenerative changes from alcohol, 142 
Delpeuch, 286 
Dengue, diet for, 229 

Dextrins, percentage of, in malt liquors, 146 
Dextrose, 109; metabolism, in diabetes, 33; 
of portal blood, 31; stored as fat, 33 ; utili- 
zation of, 33 
Diabetes mellitus, 33, 403; acetone in, 405; 
causes, 403; classes of patients, 404; 
classes of cases, 404, 405-6; coma in, 406; 
diacetic acid in, 40s; diet for, 405: from 
alcohol, 142; Gerhardt's test, 414: glyco- 
suria in, significance of, 407; hepatic 
changes in, 404; mental depression and ex- 
citement harmful in, 415; mildest cases, 
406; moderate cases, 404; nervous lesions 
of, 404; nutritional changes in, 404; 
pancreatic lesions of, 404; recurrences of, 
407; sciatica in, 404; severe cases, 407. 
Treatment of, 414; baths, 415; exercise, 
415; outdoor life, 415; rest, 415; spa treat- 
ment, 415; waters, 415 
Diabetic coma, 406; alkaline mineral waters 
for, 406; alkaline salts for, 406; entero- 
clysis for, 406; hypodermocylsis for, 406 
Diabetics, diet for, 405; beverages, 414; 
beverages, alcoholic, 414; beverages, beer 
to be avoided, 146; bread, substitutes for. 
411; buttermilk, 409; cautious enlarge- 
ment of dietary, 406; cream, 409; eggs, 
409; fats and oils, 408; fatty foods, 27; 
fish, 409; food in, 5; foods to be avoided. 
410; fruits, 413, 414; fruits, percentages of 
sugars and carbohydrates in. 413; inter 
mittent restrictions, 408; kumiss, 409; 
lactose, 409; levulose, 409, 4>°; meats, 
408; menu for strict diet. 4'.s; milk, 409; 
milk substitutes, 409; milk-sugar, 409. 
410; nut flour, 125; nuts, 414; O'Donnell's 
bread, 411; saccharin, 410; starch, 410. 
substitutes for flour, 127. 4"; sugar, 
varieties of, 410; test diet, 405: vegeta- 
bles, 413; vegetables, kinds of, forbidden, 
413; vegetables, percentages of sugar and 
carbohydrates in, 413 
Diaphoretic, water as a, 10 
Diarrhea, 301; causes, 301; effects of sour 
wines in, 149; in gastro-intestiral influ- 
enza, 247; in cerebrospinal meningitis, 
249; prevention of, 301. Treatr.-. 



43 2 



INDEX. 



302; diet, 302; fats, harmful, 27; milk, 
302; restrictions, 303 ; soft foods following 
milk, 302; withholding of food, 302. 
Vomiting with, diet for, 303 

Diarrhea in infants, 303; causes of, 303; 
lavage, 304; treatment, 303, 304; milk, 
diluted, 304; milk, modified, 304; with- 
holding food, 304. Chronic, 309; albu- 
men-water, 309; in infants, foods to be 
avoided, 309; milk, modified, 309; milk, 
peptonized, 309; oil inunctions, 309; with- 
holding of food, 309; convalescence from, 
fresh air, 310. Summer, 304. See En- 
terocolitis. 

Diathesis, gouty, 418 

Diet changes, effects of, 35; dependent upon 
food production, 48, 49; indiscretions in 
middle life, 159; influence of, on mam- 
mary secretions, 174; indifferent periods 
of life, 158; in disease, 207 (see also Dis- 
ease, Diet in) ; in diseases of the blood, 288 ; 
in diseases of the circulatory organs, 334; 
in diseases of the intestines, 301; in dis- 
eases of the kidneys, 345; in diseases of 
the liver, 317; in diseases of the nervous 
system, 364; in diseases of the peritoneum, 
323; in diseases of the respiratory organs, 
3 2 s ; in diseases of the skin , 3 7 7 ; in diseases 
of the stomach, 260; in disorders of nu- 
trition, 382; in health, 151; in infancy, 
160; in infectious diseases, 214; list for 
tuberculous patients with impaired diges- 
tion, 238; list for tuberculous patients 
with good digestion, 243, 244; lists for 
tuberculosis, 243, 244, 246; mixed, desir- 
able, 24, 108; of Mexicans of New Mexico, 
54 ; of negro field laborer and farmer com- 
pared with standard, 56; of negroes of the 
Southern States, 52; of professional men' 
51 ; of savages, 48; of the sick, general con- 
siderations of, 207, 208; relation of to 
seasons, 49; starvation, 155, 158; table, 
daily, of negro farmer and poor Mexican, 
55; table of students' boarding clubs in 
State colleges, 53; table of women 
students' clubs, 53. See also Dietaries; 
Dietary; and Feeding. 

Dietaries and dietary standards American 
and European, 46; of athletes, 156; of 
football teams, 156; of inhabitants of the 
United States, 49; of mechanics, 50; of 
professional men, 50; of student clubs, 50; 
of university boat crews, 156, 157 

Dietary, American, unbalanced, 50; equili- 
brium, 40; for achlorhydria, 275; acne, 
379; acute gastritis, 267; aged persons; 
158; anemia, 288; anemia, pernicious, 296, 
aneurysm of the aorta, 342; angina pec- 



toris, 340; arteriosclerosis, 343; arterio- 
sclerosis and atheroma, 336; arthritis 
deformans, 418; asthma, 329; athletes in 
training, 151; brain- workers, 154; bron- 
chitis, 327; bronchitis, capillary and 
catarrhal pneumonia, 327; cancer of the 
stomach, 286; cancerous obstruction of 
the pylorus, 284, 285; children, 196; 
chlorosis, 292; cholelithiasis, 320; con- 
stipation, 314, 315; diabetes, 405, 417; 
dilated stomach, 278, 279, 280; dilatation 
of the heart, 334; diphtheria, 251; dyspnea 
in heart disease, 339; dysentery, 221; 
dysphagia and odynophagia, 260; eczema, 
377; emaciation, 383; emphysema, 329; 
epilepsy, 372; empyema, 333; frontal 
headache, 364; gastralgia, 365; gastric 
catarrh in heart disease, 337; gastritis, 
acute, 266; gastritis, chronic, 268; 
gastritis, mucous, 275, 276; gastritis with 
achlorhydria, 275; gastritis with hyper- 
chlorhydria, 272 ; gastritis with hypochlor- 
hydria, 273; gastric ulcer, 282; gout, and 
goutiness, 422; hyperchlorhydria, 271; 
hypochlorhydria, 273; influenza, 247, 248; 
insomnia, 371; intercostal neuralgia, 365; 
jaundice, 317; kidney failure in heart dis- 
ease, 338; laryngismus stridulus, 326; 
leukemia, 299; migraine, 366; measles, 
233; nephritis, acute, 355; nephritis, 
chronic diffuse, 357; nephritis, interstitial, 
361; neurasthenia, 368; obesity, 388, 391; 
oxalic acid calculi, 346; osteomalacia, 
397 ; palpitation of the heart, 340; pleurisy 
with effusion, 332; pyelitis, 363; rachitis, 
395; rest cure, 367; rheumatism, articular, 
acute, 254; rheumatism, articular, sub- 
acute, 256; scarlet fever, 231; scurvy, 399; 
smallpox, 230; tuberculosis, 237; typhoid 
fever, 214; ulcerative laryngitis, 325; 
uremia, 351; uric acid calculi, 346; vomit- 
ing, 262; weak heart, 336; whooping- 
cough, 249 

Dietetics, principles of, 3 

Dietotherapy, 3 

Digestion, checked by emotional excite- 
ment, 19; churning movements of the 
stomach as an aid to, 19; delayed by wine, 
149; impaired by excess of salts, 37; 
salivary, 30; effects of alcohol on, 136; 
effects of beer on, 146; effects of brandy 
on, 136; effects of cocoa drinking on, 135; 
effects of coffee drinking on, 132; effects 
of intense mental work on, 154; effects of 
tea drinking on, 130; effects of violent 
exercise after meals on, 153; effects of 
wines on, 149; of carbohydrates, 29; of 
carbohydrates, intestinal, 3 1 ; of fatty food, 






INDEX. 



433 



24; of milk, 76; of proteins, 18; of proteins, 
diagram of, 18; of starch, 29 

Digestive disorders, banana meal for, 121; 
disorders, diet in, 260-280; disorders in 
chronic cardiac disease, treatment of, 337; 
processes lessened by fever, 37. See also 
Indigestion. 

Dilatation of the heart, 334, 335. See 
Heart, Dilatation of. 

Dilated stomach, 277. See Stomach, Di- 
lated. 

Diphtheria, 250; albuminuria in, 250; albu- 
min uria in, milk diet for, 250; convales- 
cence from, diet for, 251; conveyed by 
milk, 72, 202; enteroclysis for, 251; febrile 
stage, gruels, 251; febrile stage, milk, 251 ; 
feeding by nasal or esophageal tube, 250; 
hypodermoclysis, 251; intubation, 251; 
intubation, feeding after, 251; intubation, 
feeding after, Casselberry's method, 252; 
nephritis in, 250; nutritive enemata, 250; 
paralysis after, feeding in, 252; paralysis 
after, nutritive enemata and stomach- 
tube, 252; saline solutions, 252; soft foods, 
251; water, 250 

Disaccharids, 29 

Disease, diet in, 207; concentrated foods, 
208; concentrated foods, carbohydrates, 
210; concentrated foods, malt extracts; 
210; concentrated foods, proteins, 209; 
fats and oils, 210; general considerations, 
207; rectal feeding, an. See also under 
the various diseases. 

Disease from uncleanliness in preparation 
and serving of foods, 201; food as a cause 
of, 200; utility of milk in, 78 

Diseases, chronic lessening of digestive pro- 
cesses in, 32; chronic wasting, fatty food 
for, 27; infectious, diet in, 214; chlorea, 
224; diphtheria, 250; dengue, 229; 
dysentery, 221; erysipelas, 234; influenza, 
247; malaria, 236; measles, 233; menin- 
gitis, cerebrospinal, 249; relapsing fever, 
229; scarlet fever, 231; seyticemia and 
pyemia, 235; smallpox, 230; tuberculosis, 
237; typhoid fever, 214; typhus, 220; 
whooping-cough, 248; yellow fever, 222. 
See also under Diet and Dietary. 

Distillation, water purified by, 12 

Distilled alcoholic beverages, 144 

Diuretic, water, as a, 10 

Dried apples, 120; beans, 117; fruit, 120; 
olives, 123 

Drinking, indiscretion in, ill effects of, 8, 201. 
See also Alcohol; Beverages; and Water. 

Drinking-water, 7-12 

Dropsy, 322, 338 

Drugs, effect of, on mother's milk, 173 

28 



Dujardin-Beaumetz, 225, 387, 

Dulcin as a sugar substitute, 128 

Duodenitis in catarrhal jaundice, 317 

Dupre\ 148 

Dysentery, 22 1 ; diet in, 221; beef juice, 222; 
demulcent drinks, 222; milk diet, 221; 
shredded fish, 222; soft eggs, 222; with- 
holding food, 221; Convalescence, diet 
for, 222. Chronic, inunctions of oils, 
222; milk diet, 221; milk diet modified, 
221. Remission, diet for, 222; farinace- 
ous foods, 222; meats in, 222 

Dyspepsia, 263; dietetic treatment of, 264; 
functional, 263. Nervous, 264, 36s;gas- 
tralgia in, rest cure for, 36s 

Dyspeptics, coffee harmful for, 133; sugar to 
be restricted, in; tea harmful for, 131 

Dysphagia, and odynophagia, 260; artificial 
feeding, 261; causes of, 260; cocain spray, 
261; cold foods, 260; concentrated foods, 
260; hot foods, 261; ice-cream, 261; intu- 
bation of esophagus, 261; nutritive 
enemata, 261; orthoform, 261; soft foods, 
260 

Dyspnea in heart disease, 339 



Eastes, Dr., 72 

Eating, excess in, ill effects of, 200 

Ebstein, 386, 387 

Eczema, 377; causes, 377; dietetic causes, 
377; foods to be avoided, 378; in infants, 
378; in the poor, 378 

Edam cheese, 86 

Edema in chronic heart-disease, 338 

Effusion, pleural, diet in, 332 

Egg coloring, poisoning by, 20.? 

Egg-labumen, 89; use of, in rectal feeding, 
211 

Egg-nog, 90 

Eggs, 88, 294; absorption of, 89; biliousness 
from, 90; boiled, 90; digestibility of, 89; 
hard boiled, digestibility of, 89; hen's. 88; 
in rectal feeding, 213; modes of adminis- 
tration of, 89; poached, 90; raw, 89; salts 
in, 89; in tuberculosis, 242 

Eicholz, 89 

Electric light bath. 259 

Electricity in achlorhydria. 275 

Elimination of end products of carbohy- 
drate-metabolism. 33; of end products of 
fat-metabolism, 26; of mineral salts. 39: 
of protein waste, 22; of water. 9. water 
Mtial to. 10 

Emaciation. 382; beverages in. 384: causes 
of, 382; diet for. 383; from j>oor digestion. 
34; menu for. 384; treatment of, 383 

Emphysema, 329; diet in, 329 



434 



INDEX. 



Empyema, 333 ; diet in, 333 

Ems, 16, 319 

Emulsification of fats and oils, 26 

Emulsions of fats and oils for invalids, 210 

Endermic feeding with oils, 210 

Endocarditis, acute. 324, 334 

Endurance of athletes, 152 

Enema, Leube's pancreas, 2 13 

Enemata, acid, in cholera, 226; nutritive, 
210; nutritive, albumoses, 211; nutritive, 
beef juice, 211; nutritive, eggs with salt, 
211; nutritive, opium added to, 212; 
nutritive, peptones, 211; nutritive, starch, 
211; nutritive .various preparations, 213 
(see also Feeding, Rectal); of water, 11; 
saline, n. See also Enteroclysis. 

Engel, 199 

English army ration, 43 

Enteritis, from overeating, 200; with 
diarrhea in measles, 233; membranous, 
310; broths as substitutes for milk, 310; 
Jacobi's milk mixture, 3 10; milk, modified, 
310; over feeding between attacks and 
during convalescence, dangers of, 310; 
withholding of food, 310 

Enteroclysis, 11; in cholera, 226; in cholera 
infantum, 306; in diabetes, 406; in diph- 
theria; 266; in erysipelas, 234; in gastritis, 
266; in jaundice, 318; in nephritis, acute, 
356; in scarlet fever, 231; in septicemia 
and pyemia, 235; in typhoid fever, 218; in 
yellow fever, 223. 

Enterocolitis, chronic, in adults, 308; al- 
buminous diet, 308; cereal foods, 308; 
dangers from overfeeding, 309; foods to be 
avoided, 309; idiosyncrasy against milk, 
308; milk diet, 308; milk pancreatinized, 
308; withholding of farinaceous foods, 
308; vegetables, 309; Convalescence from, 
foods easly digestible, 309 

Enterocolitis of summer diarrhea in infants, 
304; causes, 304; Treatment of, 305, 306; 
anodynes, 306; antiseptics, 306; astrin- 
gents, 306; change of air, 306; farinaceous 
waters, 305; flushing the colon, 306; milk, 
modified, 305; milk sterilized or Pasteur- 
ized, 305 ; withholding of milk, 305 ; stimu- 
lants, 306 

Epilepsy, 372; abstemiousness, 372; diges- 
tive errors, 372; in childhood, 375; menu, 
373 

Epithelial cells of the intestines, action of, 20 

Equilibrium, carbon, 41; dietary, 40; nitro- 
genous, 40 

Ergotism, 202 

Erysipelas, 233; albuminuria in, 234; liquid 
and soft foods, 234; nephritis in, 234; 
saline infusion, 234; water, 234 



Esophagus, stenosis of, gastrostomy, 261; 
stenosis of, intubation, 261 

Ethers, vinous, 148 

Ethyl alcohol, 135. See Alcohol; and Bev- 
erages, Alcoholic. 

Eucasein, 209 

Eureka Springs, 16 

Excretion of proteid waste, 22 

Exercise for brain workers, 155; harmful 
effects of eating immediately after, 154; 
influence of, on mammary secretions, 174; 
moderate, after meals, 153; violent, after 
meals, effects on digestion, 153 

Extractives in wine, 147 



Fairchild's panopepton, 209 

Farina, 115 

Farinaceous food in infant feeding, 193; 
waters in summer diarrhea, 305 

Fat as a proteid-saving food, 24; absorption 
of, 25; accumulation of, in tissues, 24; 
body, sources of, 24; dextrose stored as, 
33 ; excess of, as a cause of indigestion, 26; 
food, uses of, 24; in egg yolks, 79; in fore- 
milk,' 171; in mother's milk, increase of, 
by diet, 173; meats, digestibility of, 26; 
metabolism, end-products of, 26; mutton, 
not digestible, 26; of milk, 68; oxidization 
of, 26; percentage of, in subsistence ration, 
42; pork not digestible, 26 

Fatigue, effects of alcohol on, 141 

Fats and carbohydrates as nitrogen savers, 
40; and oils, 24; and oils as laxatives, 27; 
and oils, emulsification of, 26; and oils for 
invalids, 210; and oils, percentage of, in 
various foods, 27; animal, in dietetic use, 
2 7 ; animal , in digestion, 2 6 ; as producers of 
calories, 42 ; forbidden in acute and chronic 
diseases of stomach, liver, intestines, 27; 
harmful in diarrhea, 27; in cocoa, 135; in 
coffee, 132; in milk, 6; retention of, from 
use of alcohol, 139; sources of, 6; use of, in 
constipation, 27; vegetable, in dietetic 
use, 28 

Fatty acids in cheese, 87; food, digestion of, 
24; food for rickets, 27; food in chronic 
wasting diseases, 27; food in diabetes, 27; 
405; food in disease, 27; food in tuberculo- 
sis, 27, 240; foods, 26; foods in conval- 
escence, 27; metamorphosis from alcohol, 
142 

Feeding, artificial, in dysphagia, 261; arti- 
ficial, in pseudoleukemia, 300; bottles, 
kinds and care of, 195, 196; forced, in 
cerebrospinal meningitis, 249; forced, in 
diphtheria, 251; forced, in mental diseases, 
376; forced in tuberculosis, 240, 241, 



INDEX. 



435 



1 71-199; infant, 143-166; infants, rules 
for, 179 (see Infant Feeding); mixed, for 
infants, 194, 195; Rectal, 211; articles of 
food for, 213; foods for, 211; foods suit- 
able for, an; for acute generalized peri- 
tonitis, 324; achlorhydria, 275; cerebro- 
spinal meningitis, 249; diphtheria, 2s 1; 
dilated stomach, 279; dysphagia, 261; 
gastritis, 266; gastric cancer, 286; intesti- 
nal obstruction, 311; leukemia with 
stomatitis, 300; malaria, 237; pernicious 
anemia, 299; pyloric obstruction, 286; 
scarlet fever, 231; smallpox, 230; typhoid 
fever, 218; typhus fever, 221; ulcerative 
laryngitis, 325; uncontrollable vomiting 
in pregnancy, 263; uremia, 351; whooping 
cough, 248; formulas of foods for 213; 
methods of, 211; quantity for, 211. (See 
also Enemata, Nutritive.) Feeding the 
sick, 207. 

Fermentation, abnormal, in alimentary tract, 
31; alcoholic, in sugars, 11 1; bacterial, 
in slow carbohydrate digestion, 32; bac- 
terial, in stomach and intestine, 21; buty- 
ric acid, in sugars, in lactic acid, in 
sugars, in 

Fermented alcoholic beverages, 144 

Fever, catarrhal, 247. See Influenza. 

Fever, enteric, 214. See Fever, Typhoid. 

Fever, increase of abnormal fermentation 
from, 32; lessening of digestive processes 
in, 155 

Fever, intermittent, 236. See Malaria. 
Malarial, 237. See Malaria. 

Fever, relapsing, 229; complicated with 
jaundice, milk diet, 229; convalescence 
from, soft and solid foods, 229; diet for, 
229 

Fever, remittent, 236. See Malaria. 

Fever, scarlet, 231; albuminuria in, 231; 
cool drinks, 231; convalescence, beverages, 
232; convalescence, soft foods, 232; des- 
quamation period, 231; desquamation 
period, diet in, 231; diet for, 231 ; entero- 
clysis, 231; fruits, 231; gruels, 231; hypo- 
dermoclysis, 231; ice-cream, 231; kumiss, 
232; liquid diet, 232; matzoon, 232; milk, 
232; nephritis averted by milk diet, 
231; nephritis caused by improper diet, 
231; nephritis in, 231; rectal feeding, 231 

Fever, typhoid, 214; alcoholic beverages in, 
220; diet for, 214; barley gruels, 216; bev- 
erages, 216; bouillon, 216; buttermilk, 
216; coffee, 217; fniit juices, 217; 
jellies, 217; kumiss, 216; malted milk, 216; 
milk, 214, 215; milk following Brand 
bath, 215; milk modifications, 216; milk 
substitutes, 216; milk, pancreatized, 216 



wheat gruels, 216; dietetic indications, 
219; digestive agents, for protein indiges- 
tion in, 216; rectal feeding in, 218; 
relapses in, 219; from improper feeding, 
219; saline infusions, 218; water, 217- 
Convalescence from, diet for, 218; solid 
food, when given, 218 
Fever, typhus, 220; alcohol, 221 
feeding after, 221; dietetic ind:* . 
220; drinks, 220; gruels, 220; meat juice, 
220; milk, 220; rectal feeding, 221; water, 
220 
Fever, yellow, 222; albuminuria in, 223; ku- 
miss, 223; meat juice, 223; milk, 223; 
nursing, 222; nutritive enemata. 223; 
saline infusions, 223; uremia, 224; vomit- 
ing in, treatment, 223; water, 22.3; with- 
holding food, 223; Convalescence from, 
soft foods, 223 
Fibrinogen, 68 

Fibroid changes from alcohol, 142 
Figs, 120 

Filter, Pasteur or Chamberlain, 13 
Filtering, water purified by, 13 
Filters, care of, 12 

Fish, 97, 294; digestibility of, 98; digestion of, 
98; mollusks, crustaceans, etc., compo- 
sition and fuel value of various kinds, 105, 
106; poison in, 202; preserved, composi- 
tion and fuel value of various kinds, 106 
Flatulence caused by beans, 117; from beer, 

146; from tea-drinking, 131 
Flesh, plant poisons in, 202 
Flies as carriers of disease germs to foods, 

202 
Flour, 112; almond, 411; baked, 113; bali. 
77; cocoanut, 411; peanut, 41 ' 
tion of, 112; products, starch percentage 
of, 410 
Food adulteration, poison from, 202; after 
prolonged starvation. 158, alcohol as a, 
138, 139; animal and vegetable, ratio 
between, 108; animal, lack of. in diet of 
negroes, 55; animal, lack of, in d 
poor Mexicans. 55; as a eu- 
genic matter, 200; as a cause of ( 
200; carbohydrate, 19; Cfl 
action of liver on, 3 r and 

quantity of, for delicate stomachs, 279; 
deleterious chemical compounds in. 202; 
digestibility of, for brain workers. 154; 
eaten as potential MM If] 
18, 19; elements, carl 1 
ments, fats and oils. 14; (HBDMI 
teids. 18; eU-nictr 
proteids and calories, 4.-. h 
infant feeding ior. h 

194; harmful 



43 6 



INDEX. 



effects in pathologic states, 54; idiosyn- 
crasies against, 204; ill effects of, 200; in 
diabetes, 5 ; in disease, 207 ; in health, 3 ; 
in old age, 40; in prehistoric times, 48; 
inspection, 201; needed in adult life, 40; 
nitrogenous, tissue waste from excess of, 
41; parasites and micro-organisms in, 201; 
poisoning by, 87, 202; preservative, sod- 
ium chlorid as a, 37; preservatives, 
poisoning from, 202; proteins and calories 
in, needed to sustain life, 42; quantity and 
kinds needed, 40; required by average 
man, 43; utilization of, 4; value of cocoa, 
134 ; values of various articles (see Tables) ; 
varieties of, for young children, 197 

Foods, animal, 6, 68; eggs, 88; fish, 97; 
meats, 90; milk and milk products, 68 

Foods, chemical classification of, 6; concen- 
trated for invalids, 208; fatty, 26; for 
diabetics, 410, 411; fried, not digestible, 
27; inorgan c, 6; interrelationship of, 34; 
laxative for constipation, 314, 315; or- 
ganic, 6; proprietary, in infant feeding, 
192; unsuitable kinds for young children, 
i97 

Foods, vegetable, 6, 107; cereals, in; fruits, 
120; fungi, 127; greens, 118; nuts, 126; 
peas and beans, 117; roots and tubers, 115; 
spices and condiments, 128; sugars, 107, 
109; various, iron content of Bunge's list 
293; various, protein percentage in, 22 

Foodstuffs, chemical composition of, table 
showing, 4; interrelationship of, diagram 
showing, 34 

Foot-ball teams, dietary for, 156 

Fore-milk, 171, 172; bacteria in, 179 

Formaldehyd, effect of, on digestion, 203; 
effect of, on food, 202 

Formulas of food for rectal feeding, 2 13 ; for 
milk modification, 187 

Fortified wines, 147, 149 

Fowler, 246 

Franzenbad, 17 

Fraser, 400 

Frog's legs, composition and fuel value of, 
106 

Fruit acids, 120; cooking of, 120; diuretic 
properties, 120; dried, 120; for young 
children, 197; juices and syrups, 121; lax- 
ative properties, 122; preserved, 121; 
refreshing properties, 120; sugar, 109; 
sugar, digestion of, 30; unripe, harmful 
effects of, 120, 121 

Fruitarians, 58 

Fruits, 120; as antiscorbutics, 120; as laxa- 
tives, 122; classification of, 120; compo- 
sition of, 120; composition of various 
kinds, 125; digestibility of, 121; fermen- 



tation of, 121; insufficiency of, scurvy 
from, 201; percentage of sugar and carbo- 
hydrates in, table of, 413; spiced, 121 

Fungi, 127; digestibility of, 127 

Furunculosis, dietetic and hygienic treat- 
ment, 380 



Gall-stones, cholelithiasis or, 318; causes, 
319; Treatment, 319; alkaline, saline 
waters, 319; diet, abstemious, 320; fat 
limited, 27; foods to be avoided, 320; 
mineral water health resorts, 319, 320; 
olive oil, 320; water, 319. Colic in, 320; 
prevention of, 320; exercise, inspiratory, 
320 

Game, high, poisoning by, 202 

Garrod, 398 

Gastralgia, 365; causes, 365; generous diet, 
365; idiosyncrasies, 365; rest cure, 365; 
restriction of diet, 365 

Gastric and intestinal disorders, acute, from 
overeating, 200; cancer, 284 (see also 
Cancer, Gastric) ; digestion, effects of 
alcohol on, 136; digestion, effects of beer 
on, 146; digestion, effects of cocoa on, 134; 
digestion, effects of wines on, 149; dila- 
tation from overeating, 200; distress from 
tea-drinking, 131 

Gastric hemorrhage, 281 (see also Hemor- 
rhage, Gastric); incompetency, menu for, 
276, 277; ulcer, 281 (see also Ulcer, 
Gastric) 

Gastritis, acute, 264; causes, 264; 265; alco- 
holic beverages, 265; chemical irritants, 
265; irritating food, 264, 265; mechanical 
irritants; 265; traumatism, 265; treat- 
ment, 266 ; alcoholic beverages forbidden, 
268; diet, 267; enteroclysis, 266; hypo- 
dermoclysis, 267; idiosyncrasies against 
food, 265; milk, 267; nutritive enemata, 
266; withholding of food, 266; treatment 
for thirst, 267; vomiting, 266; champagne, 
268; cold effervescent drinks, 267. Con- 
valescence from, diet for, 268 

Gastritis, atrophic, 269 

Gastritis, chronic, 268; causes, 268; alcohol, 
268; diseases predisposing, 269; mental 
depression, 269; overeating, 200, 268; 
classification, clinical, 269; pathologic, 
269; prevention of, 269, 276; foods to be 
avoided, 276; Treatment, 270; beverages, 
276; change of diet, 270; diet, 270; foods 
to be avoided, 270; methods of cooking, 
270; rest and recreation, 269 
Chronic catarrhal in heart disease, treat- 
ment of, 337 ; in tuberculosis, diet for, 239, 
240; With achlorhydria, 275; constipation 



INDEX 



437 



in, treatment, 275; buttermilk as a laxa- 
tive, 275; honey as a laxative, 275; stewed 
fruits as laxatives, 275; diet, 275; milk, 
275; nitrogenous foods, 275; predigested 
foods, 275; sugars and starches in liquid 
form, 275; general treatment, 275; diges- 
tive agents, 275; electricity, 275; exercise, 
275; hydrotherapy; 275; lavage, 275; 
nutritive enemata, 275 
With hyperchlorhydria, 271 ; treatment, 
an; diet, 271, 272; alkalies, 271; foods to 
be avoided, 272; lavage, 271; milk, 271. 
Convalescence, soft foods, 271. With 
hypochlorhydria, 272; treatment, 273; 
beverages, 274; carbonized waters, 274; 
diet, 273; diet, change of, 274; exercise, 
2 74; hot water, 2 74; spas and climates, 274 

Gastritis in catarrhal jaundice, 314; mucous, 
270, 274; hot water, 274; liquid foods, 274 

Gastro-intestinal influenza, 247 

Gastrostomy, 261 

Gavage for tuberculosis, 241 

Gelatin, 97; in aneurysm, 343; as a protein 
sparer, 97; jellies, 96 

Gerhardt, 405 

Geyser Sorings, 15 

Glenwood Springs, 17, 258 

Gin, 145 

Globulins, 109 

Glucose, 109 

Glycerin in wine, 147, 148 

Glycogen, carbohydrates chief source of, 33 

Glycosuria, alimentary, no. See also 
Diabetes. 

Gordon, George E., 184 

Gout, 418; causes, 418; alcohol, 142; beer 
and stout, 146; meat diet without exercise, 
23; overeating, 200; wine, 149; definition of, 
418; Treatment, 421; abstemiousness, 422; 
alcoholic beverages harmful, 423; alka- 
line purgative waters, 424; beverages, 
424; diet, 422; carbohydrates, 423; eggs, 
422; fat, moderate use of, 423; fish, 422; 
fish, kinds to be avoided, 423; foods to be 
avoided, 423; fruits, 423; meat, 423; milk, 
422; vegetables, 423; exercise, 425; min- 
eral waters, 424; water, 424 

Gout, acute, prevention of, 421, 425; and 
goutiness, 4 '8 

Goutiness, 418; causes, 418; definition, 418; 
treatment, 421 ; alkaline purgalive waters, 
424; alcoholic beverages, 423; beverages, 
423; carbohydrates, 423; eggs, 422; exer- 
cise 425; fat 423; fish, 422; foods to be 
avoided, 422; fruits, 421; meat, 423; 
milk, 422; mineral waters, 424; soups, 
422; temperance, 422; vegetables, 423; 
water, 424; well-balanced dietary, 424 



Gouty diathesis, 418; state, 422 

Grain mixture in whisky, 144; table show- 
ing chemical composition of, 112 

Grains as substitutes for coffee, 133 

Granose 115 

Granum, 194 

Grape cure, 122; cure for tuberculosis, 242; 
sugar, 109; sugar for rectal feeding, 211; 
sugar in digestion, 30 (see also Sugar and 
Diabetes) 

Grapes, 120 

Greek wine, chemical composition of, 148 

Green vegetables, 118. See Vegetables. Green. 

Greens. See Vegetables, Green. 

Gullet, painful disease of, 260 

Guyot, Jules, 249 



Hammarsten, 189 

Hammond, 139 

Harley, Vaughan, no 

Harrington, 69 

Harrowgate, 17 

Hauserman, 289 

Hayem, 225, 227, 228 

Hayem's saline solution, 227 

Headache, frontal, diet for, 364 

Heiser, 402 

Heart and blood-vessels, effects of alcohol 
on, 137, 138 

Heart, dilatation, acute, 334; abstemious 
diet, 334; rest, 334; restriction of fluids, 
334; dilatation, chronic, diet, 334; fatty 
infiltration of, 340; irregularity of, due to 
digestive disorders, 339; palpitation of, 
340; dietetic regulation, 339, 340 

Heart diseases, chronic, 335; anasarca in. 
339; anemia in, 338; diet for, 340; dropsy 
in treatment of, 339; dropsy, milk diet 
useless for, 339; due to arteriosclerosis, 
diet for, 336; due to atheroma, d 
336; dyspnea in, 339; edema in, 338; 
renal failure in, diet for, 338; renal failure 
in, milk diet for, 338; treatment of, 336; 
uremia in, 338; use of alcohol in, 339 
Muscular, 335 

Valvular, compensated, 336; progressive, 
dietetic treatment, 336; foods to be avoid- 
ed, 336; milk, 336; rest, 33'* 
with broken compensation, u;; difl 
disorders in, 337; foods suitable 
exercise, graduated, 337; gener.i: 
ment, 337; rest. 33 7 

Heart, weak, 335;; causes, jj$; chronic 
catarrhal gastritis in, treatment I 
climbing exercise, 388, 389: in obesity, 
340, 388; graded exercise, 389; massage. 
389 



433 



tNDEX. 



Heat production lessened by alcohol, 140 

Heberden, 421 

Hematemesis, 281, 287 

Hemorrhage, gastric, 281; gastric, treat- 
ment of, 281; ice, locally, 282; nutritive 
enemata, 282; styptics, 282; withholding 
of food, 282 

Hemorrhoids from constipation, 312 

Hepatic. See Liver. 

Hericourt, 240 

Hives, 380; from fruits, 122 

Hock, chemical composition of, 148 

Hoffman, Mr., 52 

Homburg, 17, 274, 319 

Hominy, 114 

Honey, 109 

Hops, use of, with malt, 14s 

Horlick's food, ns, 193 

Hot breads, harmful effects of, 31 

Hot Springs, Ark., 258 

Huebner, 249 

Hulshoff-Poe, 402 

Human milk. See Milk, Human. 

Hungarian wine, chemical composition of, 
148 

Hunter, 296 

Hunyadi Janos, 17 

Hutchison, 81, 86, 96, 112, 119, 125, 140, 145 

Hydrochloric acid, in digestion of proteins, 
18; acid for protein indigestion in typhoid 
fever, 216 

Hyperchlorhydria, 271 ; in chlorosis, treat- 
ment of, 291; See also Gastritis, Chronic, 
with Hyperchlorhydria. 

Hypochlorhydria, 272. See also Gastritis, 
Chronic, with Hypochlorhydria. 

Hypodermic feeding, 210 

Hypodermoclysis, 11; in cholera, 228; in 
diabetes, 406; in diphtheria, 251; in ery- 
sipelas, 234; in gastritis, 266; in intestinal 
obstruction, 311; in jaundice, obstructive, 
and grave jaundice, 318; in nephritis, 356; 
in scarlet fever, 235; in septicemia and 
pyemia, 231; in uremia, 351 

Hysteria, neurasthenia and, regime, 367, 
369; rest cure, 367 



Ice-cream, 30, 83 

Iced food and drinks, digestion hindered by, 

30; water, harmful effects of, 10 
Iceland moss, 128 
Idaho Hot Springs, 16 
Idiosyncrasies against foods, 204; in asthma, 

329 
Idiosyncrasy against eggs, 90; against fruits, 

121; against milk in typhoid fever, 216 
Imperial granum, 115 



Impurities in drinking water, 12; in foods, 
202 

Indigestion as a cause of albuminuria, 349; 
as a cause of oxaluria, 346; from cocoa, 
134; from overeating, 155, 200; from 
sputum-swallowing in tuberculosis, 238; 
from tea-drinking, 131; in infants from 
excessive proteid in mother's milk, 175; 
of fats, 24; of fried foods, 27; of hot fats, 
27; with uric acid calculi, treatment by 
saline waters, 346. See also Digestion; 
and Digestive Disorders. 

Infancy, diet in, 160 

Infant feeding, 171-200; barley jelly, 194; 
cleanliness of utensils in, 195; farinaceous 
food, 193; human milk, 171; in relation to 
age, 175, 178; milk modification, 185; 
irregularity in, 177; oat jelly, 194; pro- 
prietary foods in, 192; rules for, 179; sub- 
stitutes for human milk, 181; wheat jelly, 
194 

Infants, carbohydrates in relation to age of, 
175; constipation in, treatment for, 317; 
diarrhea in, 303 ; diarrhea, chronic, in, 309 ; 
effects on, of variations in mother's milk, 
175; hand-fed, management of measles in, 
233; milk composition in relation to age of, 
176; mixed feeding for, 194, 195; prema- 
ture, food for, 194; scurvy of, 398; weight, 
importance of, 196 

Infection from eating raw vegetables, 202; 
from foodstuffs, 201; from milk, 72; from 
water, 12 

Infectious diseases, diet in, 214, 252. See 
Diseases, Infectious. 

Influenza, 247; albuminuria in, 247; cardiac 
weakness in, coffee for, 247; diet in, 247; 
febrile stage, liquid diet, 248; kumiss, 247; 
milk, 247; water, 248; gastro-intestinal, 
247; diarrhea, treatment of, 247; feeding 
in, 247; nausea, treatment of, 247; vomit- 
ing, treatment of, 247; withholding food, 
247; nephritis, 247; farinaceous foods, 248; 
milk diet, 247; weakness of, 248; bever- 
ages, 248; eggs, with milk and broth, 247; 
highly nutritious foods, 248; vegetables, 
248. Convalescence from, fruits, 248 

Infusion, saline, 11; saline, Hayem's, in 
cholera, 227; saline, hypodermic, in 
cholera, 228; saline, in cholera infantum, 
307; saline, in diabetes, 406; saline in 
diphtheria, 251; saline, in erysipelas, 234; 
saline, in gastritis, 266; saline, in jaundice, 
318; saline, in nephritis, 356; saline, in 
pneumonia, 327; saline, in scarlet fever, 
231; saline, in septicemia and pyemia, 
235; saline, in typhoid fever, 218; saline, 
in yellow fever, 223; saline, intravenous, 



INDEX. 



439 



in cholera, 227. See also Enterodysis 
and Hypodermoclysis . 

Inorganic foods, 6; impurities in drinking- 
water, 12 

Insomnia, 370; causes, 370; digestive errors, 
370; malnutrition, 371. Treatment, 371; 
beverages, 371; diet, 371; rest and recrea- 
tion, 372 

Inspection of foods, 201 

Interrelationship of foods, 34 

Interstitial nephritis, 360. See also Nephri- 
tis. 

Intestinal carbohydrate absorption, 32; 
digestion of fats, 24; fermentation, bac- 
terial, 32; inflammation, effect of, on 
proteid absorption, 22. Obstruction, 311 ; 
colon flushing, 311; hypodermoclysis, 311; 
lavage, 311; nutritive enemata, 311; rec- 
tal injections, 311; vomiting in, treat- 
ment of, 311; chronic, 312; nutritive 
enemata, 312; stenosis, period of, foods 
for, 312; surgical operations, 312; treat- 
ment prior to operation, 312; conva- 
lescence from, liquid foods, 312. Worms, 
201 

Intestines, acute diseases of, fats forbidden 
in, 27. Diseases of, 301; appendicitis, 
311; cholera infantum, 306; constipation, 
312; diarrhea, 301; diarrhea in infants, 
303; diarrhea, summer, in infants, 304; 
enterocolitis, 308; obstruction, 311; tuber- 
culous, caused by sputum infection, 238 

Intestines, liver, and peritoneum, diet in 
diseases of, 301 

Intraperitoneal injection of hot milk in 
cholera, 228 

Intravenous injections of acidulated water 
in cholera, 227; of saline solutions in 
cholera, 227. See also Infusion, Saline. 

Intubation, esophageal, 261; of larynx in 
diphtheria, 251; in diphtheria, feeding 
after, 252 

Inunction of fats and oils, 210 

Invert sugar, 109 

Invertose, 109 

Iodine, 16 

Irish moss, 128 

Iron content of foods, 293; sources and uses 
of, 37 



Jaccoud, 231 
Jacobi, 310 
Jaffa, M. E., 58 
Jams, 121 

Japanese, diet of, 60 

Jaundice, catarrhal, 317; diet for, 31"; 
foods to be avoided ,318; milk, predigcstcd . 



317; convalescence from, diet for. 318; 

in relapsing fever, milk diet for, 329; 

vomiting in, 317. Obstructive and grave, 

318; milk, 318; saline infusions, 318; 

treatment, 318; water, 318 
Jellies, fruit, 121 
Jessen, 99 



Kephyr, 81; composition of, 82; fermen- 
tation, 82 

Keyser Spa, 16 

Kidney as a food, digestibility of, 98 

Kidneys, contracted, 361. Diseases of, 345; 
albuminuria, 348; from alcohol, 143; 
nephritis, acute, 353; nephritis, chronic 
diffuse, 356; nephritis, interstitial, 360; 
nephrolithiasis, 345; passive congestion, 
352; pyelitis, 363; uremia; 350. Passive 
congestion of, 352; complete rest, 352; 
foods of easy digestion, 352; milk diet, 
352; treatment to avert nephritis, 352; 
water, 3s 2. See also Albuminuria; Cal- 
culi; Nephritis; Renal; and Uremia. 

Kissingen, 17, 274, 319, 346 

Kleen, 415 

Klose, 393 

Koenig, 189. 190 

Kohlrabi, 119 

Kosher meat, 202 

Kumiss, 80; beneficial effects of, 82; compo- 
sition of, 82; cure, 82; cure for tuberculo- 
sis, 242; effects of, 82; fermentation, 82 



Lactalbumin, 68 

Lactic acid fermentation of sugars. 1 1 1 ; 
acid in cholera, 22s 

Lactose, 68-109; least fermentable of sugars, 
111; in diabetes, 409 

Lamb, chemical composition and fuel value 
of various cuts, 103 

Langworthy, C. F.. 100 

Laryngismus stridulus, 326; diet as a pro- 
phylactic measure, 326; due to ri 
diet, 326 

Laryngitis, ulcerative. 225; analgesic appli- 
cations, 325; feeding by esophageal tube, 
326; liquid and soft foods. 325; orthoform, 
325; position in swallowing, 326; rectal 
feeding, 325; syphilitic, jtSl tuberculous. 
32s 

Lathyrism. 202 

Latta, 227 

Lavage in cancer of the stomach, a 86; in 
chlorosis. 292; in cholera infantum, 307; 
in chronic mucous ga • tfl diar- 

rhea, 304; in dilated stomach, »66: in 



44Q 



INDEX. 



hypochlorhydria, 271; in obstruction of 
the bowel, 311; in pernicious anemia, 297; 
in tuberculosis, 241; in vomiting, 263 

Laxative effects of fats and oils, 27 ; effects of 
fruit, 122, 315; foods in constipation, 315; 
oil as a, for children, 317; water as a, 10, 
316 

Lead poisoning from canned vegetables, 
203; poisoning from cakes, 203 

Lecithin, 89 

Legumes, fresh and dried, composition of, 
compared with other foods, 117, 118 

Legumin, 117, 209 

Lemon oil, 128 

Lentils, 293; nitrogenous value of, 107 

Lettuce, 119 

Leube, 213 

Leukemia, 298; arsenical preparations, 
299; causes, 299; dietetic and hygienic 
treatment, 299; easily digested foods, 299, 
300; fruits, 299; laxatives, 300; milk, 299- 
out-of-door life, 299; pure water, 299; 
rest, 300; stomatitis in, bland foods, 299; 
inunctions of oil, 300; nutritive enemata, 
300; raw or soft-cooked eggs, 299; scraped 
beef, 299 

Levulose, 109; in diabetes, 409, 410; lactic 
acid fermentation caused by, 11 1 

Life, different periods of, diet in, 158 

Lime-water, addition of, to milk, 76 

Liqueurs and bitters, 145 

Lithemia from overeating, 207; from wine, 
149 

Lithemic affections from beer and stout, 146; 
disturbances from alcohol, 143 ; state, 418. 
See also Gout and Goutiness. 

Liver, action of, on carbohydrate food, 32; 
acute diseases of, fats forbidden in, 27; 
congestion of, from overeating, 200; 
digestibility of, as a food, 98; diseases of, 
from alcohol, 143; disturbances of, from 
overeating, 155; effects of alcohol on, 143. 
Cirrhosis of, 321; cause, 321; diet, 321; 
foods to be avoided, 322; milk, 321; 
treatment, 321; ascites, 323; tapping, 323. 
Diseases of, 317; ascites in, 323; chole- 
lithiasis, 318; cirrhosis, 321; gall-stones, 
318; jaundice, catarrhal, 317; jaundice, 
obstructive, and grave, 318 

Lobster meat indigestible, 97 

Locke, 160 

Loomis, H. P., 245 

Loomis Sanitarium, diet list, 245 



Macallum, 2 89 f 393 

Madeiria wine, composition of, 148 

Magnesium phosphate, source and use of, 3 7 



Magnetic Mineral Spring, 16 

Malaria, 236; diet for, 236; convalescence 
from, diet for, 236; intermittent, 236; 
remittent, 236; remittent, liquid diet, 236; 
rectal feeding, 236 

Malarial anemia, 237; cachexia, 237 

Malic acid in cider, 148 

Malt, composition of, 145; extracts, for 
invalids, 210; sugar, 109 

Malted milk, 102 

Maltose, 29, 109 

Manitou soda water, 15 

Manure, infection conveyed to vegetables 
by, 202 

Maple sugar, 109 

Margarin, 84 

Marienbad, 16, 274, 319 

Marmalades, 121 

Marsala wine, composition of, 148 

Mastication, 18; influence of, on salivary 
digestion, 30 

Mate" or Paraguay tea as a substitute for tea, 
113 

Matzoon, 82 

Measles, 233; bronchopneumonia in, 233; 
enteritis with diarrhea in, 233; hemor- 
rhagic, 233; hemorrhagic, nephritis in, 
233; pyrexial period, diet, 233; cool 
drinks, 233; milk, 233; milk, preparations, 
233; treatment, 233; coffee, 233; diet, 233; 
liquid food, 233. Convalescence from, 
treatment of, 233 

Meat as a stimulant to formation of hydro- 
chloric acid, 18; boiled, 91; broiling or 
grilling, 92; chemical composition of, 6; 
chief source of proteids, 22; diet increases 
demand for oxygen, 22; diet, influence of, 
on digestion, 22, 23; digestibility of, 92; 
effects of cooking on, 90; flavor of, 93; 
for young children, 197; frying, 92; high, 
poison in, 202; jellies, 96; kinds of, com- 
position of various, 98; kosher, 202; not 
a necessity of life, 22; powder, 114, 209; 
powder, Mosquera's, 209; powders, 96; 
powders, composition of, 96; raw, diges- 
tibility of, 90; roasted, 91; salt, scurvy 
from, 201; stewed, 91 

Meats, 90; chemical composition and fuel 
value of various kinds and cuts, 102-104; 
digestibility of, 97 

Mechanics, dietaries of, 50 

Meigs, Arthur V., 182 

Meigs, John Forsyth, 183 

Mellin's food, 115 

Membranous enteritis, 310.*^ See Enteritis, 
Membranous. 

Meningitis, cerebrospinal, 249; feeding, 249; 
forced feeding, 249; febrile stage, liquid 



INDEX. 



441 



foods, 249; nutritive enemata, 249. Con- 
valescence, diet for, 250. Remission, diet 
for, 249 

Menstruation, effect of, on mother's milk, 1 74 

Mental disease from alcohol, 142 

Mental diseases, 375; forced feeding, 375; 
individualization in, 375. Paresis, 375 

Mental work, effects of, on digestion, 154 

Menus, Beneke's for cancerous obstruction 
of the pylorus, 286; for diabetes, 413; for 
epilepsy, 373, 374; for gastric incompe- 
tency and gastritis, 276; for obesity, 391, 
392; for tuberculosis, 243, 244, 245; 
prison, 45 

Metabolism, 40; disturbance of, by alcohol 
drinking, 137 

Metchnikoff, 85 

Mexicans of New Mexico, diet of, 54, 55 

Michael, 228 

Micro-organisms, parasites and, in food, 2or; 
in drinking-water, 12 

Middle life, diet in, 159 

Migraine, 365; causes, 365; lithemic, 366; 
Treatment, 366; abstemiousness, 366; 
baths, 366; beverages, 366; diet, 366; 
foods to be avoided, 366; exercise, 366; 
respiratory, 366; waier, 366 

Milk, 68; absorption of, 78; adulteration, 71; 
bacterial contamination of, 72; boiled, 77; 
bottles in infant feeding, cleansing of, 185 ; 
186; changes in percentage composition of, 
effect of, on infants, 184; composition of, 
6, 68; condensed, 83, 191; cane-sugar in, 
ill effects of, 192; digestibility of, 192; 
effects of, 83 ; forms of, 191 ; contamination 
of, from dirt, 72; from disease of the cow, 
7 1 ; cow's, 70, 293 ; adulteration of , 7 r ; best 
substitute for human milk, 181; compo- 
sition of, 70; contamination of, 71; diges- 
tibility of, compared with human milk, 
76; variation of, 71 ; curds in the stomach, 
prevention of, 76; cure, 78; duration of, 79; 
for tuberculosis, 242; diet, diuresis from, 
79 (see also under the various Diseases) ; 
digestion of, 76; dilution of, 77; disease 
conveyed by, 72, 201; for rectal feeding, 
213; hot, beneficial effects of sipping, 76; 
human, ash of, 68; bacteriologic exami- 
nation of, 179; composition of, 69, 160; 
condition affecting the mother, in relation 
to, 172; influence of diet and exercise on, 
174; poor in protein, 69; rich in carbo- 
hydrate, 69; substitutes for, 181 ; variability 
of, 69, 70; variation of, 171; variation of, 
effects on infants, 175 (see also 
Mother's) ; idiosyncrasy against, in I | 
fever, 216; kinds of, comparative compo- 
sition of various, (>■>; laboratories. 



mixture, Meigs's, for infants. 183; ob- 
tained from use of peptogenic milk pow- 
der, 191; mixtures for infant feeding, 182; 
modification, 80, 182; at home, 185; 
formulas for, 187; percentage. 184, 185; 
quantities of various constituents for, 186; 
with cream and whey, 189; mother's, 
clinical analysis of, 176; constituents, 
various, how increased or decreased, 173, 
174; effects of menstruation on, 174. 
effect of pregnancy on, 174; fat in, how 
increased, 173, 174; fat in, how decreased, 
174; in relation to infants' illnesses. 175; 
influence of diet and exercise on, 174, 175: 
proteid, how increased in, 173; proteid, 
how lessened in, 174; quantity affected 
by drugs, 173; quantity affected by water 
drinking, 173; quantity how decreased, 
174; quantity, how increased. 174; varia- 
tion in, effects of, on infants, 175; Pas- 
teurized, 75, 183; peptonized, 191; for 
gavage, 241; for rectal feeding, 212; 
percentage of mineral salts in, 68; modi- 
fication of, 183, 185; Philadelphia Pediat- 
ric Society's, 75; prcdigestion of, 79. 191; 
preservation of, 83; products, 68; recepta- 
cles, sterilization of, 184; skimmed, ,s -, ; 
sterilization and Pasteurization of, 75; 
strippings, 172; substitutes for, in typhoid 
fever, 216; tester, Babcock's, 177. utility 
in disease, 7 8 

Milk-sugar, 68, 109; digestion of. 30; in 
diabetes, 409, 410 

Mineral ingredients of body, 36; salts. 37: 
salts, how obtained, 6; salts of milk, 68; 
water health resorts for gall-stones, 320; 
for gout, 424. See also under the various 
Diseases. 

Mineral waters, 13; classified. 14 

Mitchell, C. Ainsworth, 100, 102, 103, 104 

Mitchell, S. Weir, 368. 369. 383 

Mixed diet, 108 

Mocha coffee 

Molasses, 109, 144 

Mollusks, composition and fuel I 
various kinds, 106 

Monosaccharids. 29 

Moral perception lessened by UM 

Morbilli, 833. See i\fcasles. 

Morgagni, 342 

Morro, no 

Morro and Harlcy, 1 10 

Mosquera's beef meal, 96 

Mother, conditions affecting, in 

milk. 172 
Mother's milk. 1 ; 1 
.rr's. 



442 



INDEX. 



Mount Clemens Spring, 17, 25S 

Mouth, painful disease of, 260 

Mucous disease of bowel, or membranous 
enteritis, 310. See Enteritis, Membran- 
ous. 

Mucous gastritis, 2 74. See Gastritis, Chronic 

Mud baths, 259 

Muscular and nervous work, balance be- 
tween, 155; energy, effects of alcohol on, 
141 

Mushrooms, 127 

Mustard, 128 

Mutton, chemical composition and fuel 
value of various cuts, 103; fat not 
digestible, 26 



Nausea in cerebrospinal meningitis treat- 
ment of, 249; in gastro-intestinal influ- 
enza, treatment of, 247 

Navy ration, United States, 43 

Nephritis, acute, 3531 causes, 353; gastro- 
intestinal toxins, 353; food, 354; in diph- 
theria, avoidance of, 250; in erysipelas, 
234; in influenza, 247; in measles, 233; in 
scarlet fever, 231, 353; in septicemia and 
pyemia, 235; in smallpox, 230. Treat- 
ment, 354; diet, 355; milk, 355; milk, 
adjuvantsto, 354; enteroclysis, 356; 
hypodermoclysis, 356 

Nephritis, chronic diffuse, 356; causes, 356; 
dietetic, 356; edema in, 358; in drunkards, 
357. Treatment, 357; climatic and spa, 
359; diet, 358; albuminous foods, 358; 
foods to be avoided, 358; milk, 357; milk; 
modified, 357; selected mixed, 357, 
hygienic, 359; saline waters, 359; water, 359 

Nephritis, interstitial, 360; causes, 360; die- 
tetic, 360. Treatment, 360; alcoholic bev- 
erages forbidden, 362; climatic and spa, 
362; diet, 360; animal, effect of, 360; 
mixed, effect of, 360; vegetable, effect of, 
360; hygienic, 363; water, 360 

Nephrolithiasis, 345; oxalic calculi, 346; 
phosphaturia, 347; uric acid calculi, 345 

Nervous system, effect on, of alcohol, 138; 
of caffein, 132; of wine, 149. Diseases of, 
364; dementia, 375; epilepsy, 372; frontal 
headache, 364; gastralgia, 365; hysteria, 
367; insanity, acute, 375; insomnia, 370; 
intercostal neuralgias, 364; mania, 375; 
melancholia, 375; mental diseases, 375; 
migraine, 365; neurasthenia and hysteria, 
367 

Nestte's food, us, 193 

Neuenahr, 15, 319, 414 

Neufchatel cheese, 86 



Neuralgia, frontal, diet for, 364; gastric, 
treatment of, 365; intercostal, from indi- 
gestion, diet for, 365; sacral, from con- 
stipation, 312 

Neuralgias, 364; causes, 364; in the ema- 
ciated diet for, 364. Treatment, 364; 
climatic, 364; diet, 364; hydrotherapy, 
364; hygiene, 364 

Neurasthenia, 367; baths, 368; massage, 
368; milk diet, 368; regime, 369; rest 
cure, 367; sea- voyages, 367; travel, 367 

Neutrose, 209 

Nipples of feeding bottles, care of, 196; 
mother's, care of, 179 

Nitrogen equilibrium, 40; savers, fats and 
carbohydrates as, 40 

Nitrogenous food, 22. See also Food, 
Animal; Food, Vegetable; and Proteid. 

Noorden, Von, 404, 406, 412 

Nuclein, 89 

Nursing mother, rules for, 179 

Nurslings, constipation of, 317. See Con- 
stipation of Nurslings. 

Nut flours, 127, 411 

Nutrition, disorders of, 382; diabetes, 404; 
emaciation, 382; gout and goutiness, 418; 
obesity, 389; osteomalacia, 397; rachitis, 
392; rheumatism, 252; rheumatoid arth- 
ritis, 418; scurvy, 397 

Nutritive enemata, 210 (see also Enemata, 
Nutritive); value of arrow-root, 116; of 

banana meal, 121; of beef extracts, 94; of 
beef juice, 94; of beets, 116; of bouillons, 
93; of bread, 114; of carrots, 116; of 
cereals, 112, 115; of cheese, 86; of cream, 
83, of cocoa, 134; of eggs, 88; of fish, 97; 
of fruits, 120; of fungi, 127; of green 
vegetables, 118; of kephyr, 82; of kumiss, 
80; of matzoon, 82; of meat, 22; of meat 
jellies, 97; of meat powders, 96; of milk, 
69; of nitrogenous foods, 22; of nuts, 126; 
of olives, 124; of oysters, 97; of parsnips, 
116; of peas and beans, 117; of potatoes, 
116; of rice, 115; of roots, 115; of rye 
bread, 115; of sago, 116; of somatose, 209; 
of starch, 109; of sugar, no; of sweet 
potatoes, 116; of tapioca, 116; of tea, 130; 
of tubers, 115; of turnips, 116; supposi- 
tories, 213 

Nuts, 126; composition of, 126; composition 
of, compared with other foods, 126; 
digestibility of, 126 



Oat jelly, preparation of, 194 
Oatmeal, 112, 113; in diabetes, 406, 412 
Oats, 112, 293 



INDEX. 



443 



Obesity, 384; causes, 385; alcohol, 386; beer 
and stout, 146; deficient exercise, 386; he- 
reditary predisposition, 386; overeating, 
200, 386; poor digestion, 34; definition and 
effects, 384; diet for, 388; Banting, 387; 
Ebstein's, 391; Oertel's, 391; Schleicher's, 
391; starvation, 386; heart weakness in, 
treatment of, 388; in middle age, 40; in 
the anemic, treatment of, 390. Treat- 
ment, 386; alkaline waters, 389; banting, 
386; drugs, 389; exercise, 389; exercise, 
graduated, 390; hot baths, 389; therapeu- 
tic indications, 386; water, 387; work, 388 

Obstruction, cancerous, of pylorus, diet 
for, 284, 285. See also Cancer, Gastric. 

Obstruction, intestinal, 311. See Intestinal 
Obstruction. 

Obstructive jaundice, 318. See Jaundice, 
Obstructive. 

O'Donnell, 411 

Odynophagia, 260; causes of, 260; artificial 
feeding, 261; concentrated foods, 260 

Oertel, 8. 386, 387, 388 

Oil, cod -liver, 26, 28 (see Cod-liver Oil); 
olive, 124 (see Olive Oil) 

Oil, endermic feeding with, 210; hypodermic 
feeding with sterilized olive, 210; inunc- 
tions in chronic diarrhea in infants, 309; 
inunctions in leukemia with stomatitis, 
300; inunctions of cod-liver, in whooping- 
cough, 248 

Oils, fats and, 24; fats and, for invalids, 210. 
See also Fats and Oils. 

Old age, amount of food needed in, 40 

Olein, 89 

Olive oil, 123; endermic feeding with, 210; 
sterilized, hypodermic feeding with, 210; 
uses of, 124 

Olives, 123; pickled, composition of, 124; 
ripe, food value of, 124 

Onions, composition and value of, 116 

Opium, use of, with nutritive enemata, 212 

Organic foods, 6. See also under the 
various Foods. 

Oshima, 61 

Osteomalacia, 396; causes, 396; diet for, 
397; hygienic treatment of, 397; phos- 
phates for, 397 

Overeating, 155; habitual effects of, 200 

Oxalic acid calculi, 342- See Calculi, Oxalic. 

Oxaluria from overeating, 200 

Oxidization of fat in the blood, 26; of fat, 
source of body-heat, 24; processes modi- 
fied by alcohol, 139 

Oxygen, increased demand for, from meat 
diet, 22 

Oysters, 97; composition of , 97; digestibility 
of, 97, 98; typhoid bacilli in, 97 



Palmitin, 68, 89 

Pancreas enema, Leube's, 213 

Pancreatic digestion, effects of alcohol or., 

136 
Pancreatized milk, 80; milk in typhoid fever, 

216 
Panopepton, Fairchild's, 209 
Paralysis, diphtheric, feeding in, 252; per- 
sistent vascular, from alcoholic beverages. 

137 
Parasites and micro-organisms in food, 201 
Parmesan cheese, 86 
Parrot, 392 

Parsnips, composition of, 116 
Passive congestion of the kidneys, 3 3 1 

Kidneys, Passive Congestion of. 
Pasteur or Chamberlain filter, 13 
Pasteurization of milk, 75 
Pathogenic matter carried by food, 200 
Pathologic states of body, harmful effects of 

food in, 5 
Patients, tuberculous, classes of, in relation 

to food, 237 
Peanut bread, 411 
Peas, 293; and beans, 117; composition of. 

118; cooking of, 117; digestion of, 117; iron 

content of, 293 
Pentose, 120 
Penzoldt, 89, 98, 119 
Pepper, 128 
Pepsin, action of, on proteins, 19; for protein 

indigestion in typhoid fever, 216 
Peptic digestion, effects of alcohol on, 136 
Peptogenic milk powder, Fairchild's, 191 
Peptone, 19; for rectal feeding, an; in 

urine, 23; wine of, Armour's, 209 
Peptones, absorption of, 19, 20; con < 

96 
Peptonization of milk, 80, 191 
Peptonized milk, 80. S« ' 
Pericarditis, acute, and endocarditis, 334; 

dietetic indications, 334 
Periods of life, diet in the different. 158 
Peristalsis, 21 
Peritoneum, diseases of. 323: peritonitis. 

acute, 323; peritonitis, chror.i. 
Peritonitis, 323; acute, generalized, 323. 

liquid foods, 333; nutritive enenu 

treatment of, 323; vomiting in. 323; with 

holding food. 333, 324. acute, localized, 

324; chronic, diet for, 324; * 
Pernicious and progressive anemia, 294 

See Ancmxa, /VrmVwMJ an.: 
Peter, 326 
Phosphaturia, 347'. causes, 34:. vegetable 

diet, J4 7. diet for, 347 - 



444 



INDEX. 



Phthisis, 237. See Tuberculosis. 

Physiologic effects of alcoholic beverages, 
136; saline solution, 11; uses and inter- 
relationship of food-stuffs, diagram 
showing, 34 

Pickled olives, 123 

Pigeon, slow digestion of, 98 

Plasmon, 209 

Playfair, 45 

Pleurisy and empyema, 332 

Pleurisy with effusion, 332; little fluid, 332; 
milk diet, 332; Schroth method, 332; 
thoracentesis, 332; tuberculous, 333 

Pleurodynia from tea drinking, 13 1 

Pneumonia, croupous, 330; albuminuria in, 
diet for, 331; after crisis, 331; alcoholic 
beverages, 331; dietetic indications, 330; 
liquid food, 331; saline infusions, 331 

Poison, protoplasmic, alcohol as a, 136 

Poisoning by food, 203; by tyrotoxicon, 87 

Poisonous pigments in confections and 
foods, 203 

Poland Spring, Maine, 359 

Polysaccharids, 29 

Pork, chemical composition and fuel value of 
various cuts, 103, 104; fat, not digestible, 
27 

Port, chemical composition of, 148 

Porter, 145 

Postdiphtheric paralysis, 252 

Potassium bicarbonate to dissolve cheese, 
87; chlorid, source and use of, 37 

Potato, 116, 144; as a supplemental food, 
116; composition of, 115; iron content of, 
293; digestibility of, 116; sweet, 116 

Potential energy, food stored as, 41 

Poultry, chemical composition and fuel 
value of various kinds, 104 

Predigestion of milk, 79, 191 

Pregnancy, vomiting of, treatment, 263 

Preservation of milk, 83 

Prison rations, 45 

Professional men, dietaries of, 50 

Proprietary foods in infant feeding, 192 

Protein absorption prevented by intestinal 
inflammation, 22; catabolism, 41; diges- 
tion, diagram of, 20; digestion, disturb- 
ances of, 21; digestion, gastric, 18; diges- 
tion, intestinal, 19; excessive, in human 
milk, effect of, on infant, 175; food to 
increase fat in mother's milk, 173; foods 
in uremia, 351; increase of, in mother's 
milk, 174; insufficient in human milk, 
effect of, on infant, 175; lessening of, in 
mother's milk, 174; metabolism disturbed 
by alcohol, 140; metabolism, end products 
of, modified by pathologic processes, 20; 
of milk, 68; percentage of, in infant feed- 



ing, 183; sparer, fat as a, 24; sparer, 
celatin as a, 97; waste from meat diet, 22 

Proteins, 18; chemical change in, 19; concen- 
trated, 209; digestion of, 18; elimination 
of, 20; excess of, in college students' 
dietary, 153; how obtained, 6; meat chief 
source of, 22; of animal origin, 18; of 
vegetable foods, absorption of, 107; of 
vegetable origin, 18; percentage of, in 
subsistence ration, 43; percentage of, ia 
vegetable foods, 22; stimulation of body 
changes by, 41 

Proteoses, 19; absorption of, 20 

Pseudoleukemia, 300; with enlarged bron- 
chial and cervical glands, artificial feed- 
ing in, 300. 
Ptomains, 202 

Ptyalin, in starch digestion, 29 

Pulled bread, 113 

Purification of water by boiling, 12; of water 
by distillation, 12 ; of water by filtering, 12 

Putrefaction, bacterial, in stomach and in- 
testine, 21 

Pyelitis, 363; diet for, 363; bland, 363; milk, 
363; sulphur waters, 363; water, 363 

Pyemia, 234. See Septicemia and Pyemia. 

Pylorus, stenosis of, 277. See Cancer, 
Gastric. 



Rachitis, 392 ; artificial, in animals, 393 ; 

causes, 392; absence of salts, 37; dietetic 

errors, 175, 201, 392; prevention of, 394. 

Treatment, 395; broths, 395; calcium, 394, 

395; diet, 395; fats, 27, 395; kumiss cure, 

82; milk mixture, 394; milk modification, 

394; hygiene, 395; seashore, 395. See 

also Rickets. 
Radish, 119 
Rain-water, 13 
Raisins, 120 

Ratio between animal and vegetable food, 108 
Ration, army and navy, 43; subsistence not 

purchasable by the poor, 49 
Rations, English army, 44; United States 

army, 43; United States navy, 45; 

prison, 45 
Rawley Spring, 17 
Rectal alimentation, 211. See Feeding, 

Rectal. 
Rectal feeding, 211. See also Feeding, 

Rectal; Enemata, Nutritive; and Nutritive 

Enemata. 
Rectal injections for constipation of infants, 

3i7 
Rectum, absorption of foods by, 211 
Relapses in typhoid fever, 219 
Relapsing fever, 229 



INDEX. 



445 



Renal calculi, 345, 346; colic, 348; disease 
from alcohol, 143; inflammation from 
beer, 146. See also Albuminuria; Calculi; 
Kidneys, Diseases of; Nephritis; and 
Nephrolithiasis. 

Rennin, 76 

Respiratory organs, diseases of, 325; 
asthma, 329; bronchitis, 326; bronchitis, 
capillary, 327; bronchitis, chronic, 328; 
cough, winter, 328; emphysema, 329; 
laryngismus stridulus, 326; laryngitis, 
325; pleurisy and empyema, 331; pneu- 
monia, catarrhal, 327; pneumonia, croup- 
ous, 330; pulmonary tuberculosis, 237. 
Tract, chronic catarrhs of, kumiss cure, 82 

Rest cure, diet of, 367 

Rheumatic persons, regime for, 257; bath- 
ing, 257; climate, 257; clothing, 257; 
massage, 259; mineral waters, 258; rest, 
257; spas, 259 

Rheumatism, 252; Articular, acute, 252; in- 
fluence of digestive disorders in, 254; 
nature of, 253 ; prevention of heart disease 
in, 257; convalescence from, diet for, 256; 
recurrence of, 257; from wine, 149; pre- 
vention of, 257; tendency to, 256; treat- 
ment, 254; diet, 255; albuminous foods, 
256; beverages, 255, 256; broths, 255; 
fruits, 256; gruels, 255; milk, 254; water, 
254. Chronic, diet for, 256; water, 257. 
Subacute, diet for, 256; general manage- 
ment, 257, 258 

Rheumatoid arthritis, 417. See Arthritis 
Rheumatoid. 

Rice, 115, 144. 2 93; m Beri-Beri, 400, 401 

Richardson, B. W., 138, 144 

Richet and Hencourt, 240 

Richert, 99 

Richfield Springs, 17, 258 

Rickets, fatty food in, 27; in infants, from 
insufficient protein in human milk, 175; 
treatment of, 392. See also Rachitis. 

Ridge's food, 194 

Robertson, Aitchison, 11 1 

Robinson's groats, 193; patent barley, 194 

Roots and tubers, 115; composition of, 115 

Roquefort cheese, 86 

Rotch, 69, 173. i74. 183, 184. 186, 194 

Rowntree, 199 

Royet, 16 

Rubeola. See Measles. 

Rum, 145 

Rye, 293; bread, digestibility of, 114; flour, 
112, 114 



Saccharin as a substitute for sugar, 128, 410 
Sago, 116, 410 



Salicylic acid in foods, effects of, 203 

Saline infusion. See Infusion, Saline. 

Saline solution, physiologic, 11 

Salivary digestion, 30, digestion delayed, 30 

Salt in rectal feeding, 213 

Salts, 36; absence of, harmful effects of, 37; 
excess of, harmful effects of, 37; import- 
ance of supplying, 39; in eggs, 88, 99; in 
vegetables, 109; mineral, elimination 
of, 39; mineral, of cereals, 112; mineral, 
of meats, 91, 96, 101, 104; mineral, of 
milk, 68; mineral, sources of, 6, 36; of 
fish, 105, 106; of fruits, 120; of vegetables, 
"9 

Sal va tor, 15 

Samp, 114 

Samuels, 228 

Sandow, 153 

Saratoga, 16, 274, 319, 346 

Saratoga vichy, 15 

Sausage, chemical composition and fuel 
value of various kinds, 104 

Scarlatina, 231. See Fever, Scarlet. 

Scarlatinal nephrits, prevented by milk diet, 
231 

Scarlet fever, 231; fever conveyed by food, 
201; fever conveyed by milk, 72. See 
Fever, Scarlet. 

Schleicher, 392 

Schweinitz (de), 72 

Scrofula, kumiss cure, 82 

Scurvy, 397; causes, 397; from absence of 
salts of vegetable acids, 37; from con- 
densed milk, 192; from improper diet, 201 ; 
of infants, from proprietary foods, 332; 
prevention of, 398; recognition of, 399; 
treatment, 399; baths, 400; diet, 399 

Seasonal changes of diet, 48 

Seltzer, 16, 282 

Septicemia and pyemia, 234; nephritis in, 
235; Treatment, 235; diet, supporting, 
235; enteroclysis, 235; hypodermoclysis, 
197; intravenous saline infusion, 235; 
rectal feeding, 23s; water, 235. Con- 
valescence, 236 

Serum, hypodermic feeding with, 210 

Serving, daintiness in, nececssary for the 
sick, 207 

Shell-fish, 97; composition of various kinds. 
106; poison in, 97, 102 

Sherman, H. C, 21 

Sherry, chemical composition of, 148 

Shredded wheat, 115 

Sick, diet of the, general considerations of. 
214, 215; feeding the. 214: treatment of 
the, alcohol not necessary in, 14 J 

Sireday, 286 

Skatol, production of. ai 



446 



INDEX. 



Skimmed milk, 83, 114 

Skin, diseases of, 377; acne, 379; acne ro- 
sacea, 378; eczema, 377; furunculosis, 380; 
urticaria, 380 

Sleeplessness from tea-drinking, 131. See 
Insomnia. 

Smallpox, 230. Febrile stage, cool drinks, 
230; ice, 230; ice-cream, 230; liquid diet, 
230; milk, 230; rectal feeding, 230; water, 
230; albuminuria in, 230; liquid nonalbu- 
minous diet, 230; nephritis in, 230. Con- 
valescence from, soft foods, 231 

Sodium and potassium phosphates, source 
and use of, 37; and potassium sulphate, 
source and use of, 37; bicarbonate, source 
and use of, 36; carbonate, source and use 
of, 36; chlorid as a food preservative, 36; 
physiologic solution of, n; uses of, 36 

Soft waters, 13 

Somatose, 96, 209 

Soups, canned, chemical composition and 
fuel value of various kinds, 104 

Spices and condiments, 128 

Spinach, 293 

Spinal cord, effects of alcohol on, 142 

Spirits, composition of, 144 

Spring- waters, 13 

Sputum, tuberculous, swallowing of, indi- 
gestion from, 238 

Standard dietaries, 46 

Stanton, 400 

Starch, 29; digestion of, 29; digestion, cook- 
ing essential to, 29; for rectal feeding, 213 

Starches of vegetable foods, digestibility of, 
107, 108 

Starvation, 155 

Stearin, 68, 89 

Stenosis, intestinal, 311; foods for, 311; 
nutritive enemata, 311; (see also Intesti- 
nal Obstruction); pyloric, 277 (see also 
Cancer, Gastric) 

Sterilization ard Pasteurization of milk, 75 

Stewart, D. D., 203 

Stills for purifying water, 13 

Stilton cheese, 86 

Stimulant, alcohol as a, 138; coffee as a, 132; 
effect of cocoa, 134; value of beef juices, 
96 

Stomach, acute diseases of, 265; acute dis- 
eases of, fats forbidden in, 27; acute in- 
flammation of, from alcohol, 136; (see also 
Gastritis, Acute); catarrh of, in heart 
disease, diet and treatment for, 337; in 
tuberculosis, diet and treatment for, 240; 
churning movements of, as an aid to 
digestion, 19; derangements of, functional, 
263; diet in diseases of the, 260. Dilated, 
277; causes, 277; from overeating, 155; in 



strong patients, diet for, 279; in weak 
patients, diet for, 280; treatment, 277; 
diet for, 278; electricity, 279; lavage, 278; 
massage, 278; nutritive enemata, 279; 
predigested foods, 279. Diseases of, 263, 
264; achlorhydria, 275; cancer, 284; dila- 
tation, 279; dyspepsia, 263; gastritis, 
acute, 264; gastritis, atrophic, 271; gas- 
tritis, chronic, 268; gatritis, mucous, 270, 
274; hyperchlorhydria, 271; hypochlor- 
hydria, 272; ulcer, 281; vomiting, 261 

Stomatitis in leukemia, diet for, 299; treat- 
ment of, 300 

Stout, 145; or porter, brewing of, 145 

Strawberries, 293 

String-beans, 117 

Student clubs, dietaries of, 50 

Substitutes for human milk, 181 

Sugar, 29, 144; as a condiment, 128; dilu- 
tion of, in; effect of, on muscular work, 
no; effects of, on teeth, in; fermentation 
of, in; food value of, 109; in the diet of 
athletes, 151; percentage of, in beer, ale, 
stout, and porter, 146; percentages of, in 
food for diabetics, 411, 412; substitutes 
for, 128, 410; utilization of, no 

Sugars, 109; in wine, 148; of vegetable foods, 
digestibility of, 107, 108; permissibility of 
different forms of, in food for diabetics, 
408, 409, 418 

Sulphur and phosphorus, sources and uses 
of, 37 

Summer diarrhea, 304. See Enterocolitis in 
Infants. 

Suppositories, nutritive, 213 

Sweet potato, composition of, 116 

Sweetbreads, composition of, 98; digesti- 
bility of, 98 

Syphilitic laryngitis, 325 

Syrup, 109 



Table showing Absorbability of white bread 
and whole wheat bread, 114: 
Carbohydrate and sugar percentages in 
various breads, 411: 

Chemical composition and fuel value of 
animal foods, 10 1, 106: 
Chemical composition and fuel value of 
fish, mollusks, crustaceans, etc., 105, 106: 
Chemical composition and fuel value of 
meats, 101, 102: 

Chemical composition of grain, 112: 
Chemical composition of wines, 148: 
Comparative composition of various kinds 
of milk, 69, 181: 

Composition and fuel value of green veg- 
etables, 119: 



INDEX. 



447 



Composition and modification of black 
and green tea, 130: 
Composition of beef juices, 93: 
Composition of cheeses, 86: 
Composition of cocoa and chocolate vari- 
ously prepared, 135: 

Composition of flour from various cereals, 
112: 

Composition of fruits of various kinds, 125: 
Composition of legumes, fresh and dried, 
compared with that of other foods, 117, 
118; 

Composition of liqueurs and bitters, 145: 
Composition of nuts and some other food 
materials, 126: 

Composition of various preparations of 
peptone, 96: 

Daily diet of negro farmer and poor Mexi- 
can, 55: 

Diet of professional men, 5 1 : 
Diet of student's boarding clubs in State 
colleges, 53: 

Diet of women students' clubs, 53 : 
Dietaries and dietary standards, Ameri- 
can and European, 46: 
Dietaries, illustrative, in actual use, follow- 
ing page, 56: 

Dietary studies of university boat crews 
and other dietary studies, 156: 
Differences in composition and character 
of cow's milk and human milk, 181: 
Digestibility, gastric, of eggs, variously 
prepared, 89: 

Digestibility of animal foods, 99: 
Iron content of various foods, 293: 
Percentage composition of proprietary 
foods for infants, 193: 
Percentage of mineral salts in milk, 68: 
Percentage modification of milk according 
to age of child, 185: 

Percentages of starch in flour products, 
410: 

Quantities of cream and whey for infants' 
food, 189: 

Quantities of ingredients for various per- 
centages in milk, 1 86 : 
Quantities of food, and intervals between 
feedings, for infants of various ages, 178: 
Quantities of food for children of various 
ages, 196: 

Quantities of various sugars provoking 
alimentary glycosuria, no: 
Ratio of food constituents in diet of adults 
and infants, 178: 

Ration of United States army, 43 : 
Ration of United States navy, 45: 
Variation in composition of human milk, 
69, 70: 



Taka-diastase, 210 

Tannic acid enemata for cholera, 226; acid 
in coffee, 132; acid in tea, 130; acid in 
wine, 147; acid in sour wines, 150 

Tapioca, 113 

Tartaric acid in wine, 147 

Tea, 129; absorption of, 131; aroma of, pro- 
duced by volatile oils, 130; black and 
green, composition and modification of, 
130; harmful effects of, 131; making, 131; 
varieties of, 129, 130 

Tea-drinking, effects of, on digestion. 131 

Teeth, effects of sugar on, 1 1 1 

Temperature, depression of, by alcohol, 149 

Terrapin, turtle, etc., composition and fuel 
value of, 106 

Tessier, 358 

Test diet for diabetes, 405 

Theobroma cacao, 134 

Theobromin in cocoa, 134 

Throat, painful disease of, 260 

Thudicum, 320 

Tin poisoning from canned vegetables, 203 

Tissue waste from excess of nitrogenous 
food, 41; waste, increase of, from coffee, 
133 

Toast, digestibility of, 113 

Tomatoes, 119 

Trichinae, 201 

Trypsin, action of, 19 

Tuberculosis, 237; appetite in relation to 
diet in, 238; bronchial catarrh in, grape 
diet for, 242; conveyed by milk. 72; con- 
veyed by food, 201; diet for, 237: albu- 
mins, 238; alcoholic beverages. 246; raw 
beef, 240; carbohydrates, 238; cod-liver 
oil, 246; concentrated foods, 240; eggs, 
240; eggs, raw or with milk, 240; fats. 
27, 238; forced feeding. 240, 241. full 
feeding, 238; grape cure, 242; hot water 
before meals, 240; kumiss cur. 
list at Nordrach, 245. list, Brehmer's, 244; 
list for patients with good digestion, 243. 
244; list, H. P. Loomis's, 245; list of 
Loomis Sanitarium at Liberty, 245; !>*'• 
205; meat extracts, 241; meat juices, 241; 
meat scraped, 240; milk preparations. 240; 
milk, warm, before meals. 240; ofl 
predigested foods. 241; dietetic treatment, 
object of. 237; lavage before feeding, 241; 
patients, classes of. 237; pulmonar 
stages, kumiss cure. 82; fcbi. 
quiescent state, 241: with fever, diet for. 
239; with gastritis ceding. 239: 

change of scene. 240; diet. .'40; liquid 
foods, 240; rest before • therapy 

in, 240 

: mi of the intesti- 



448 



INDEX. 



sputa, 238; laryngitis, 325; patients with 
good digestion, diet for, 238; patients with 
impaired digestion, diet for, 238; pleurisy, 
333 

Tubers, roots and, 115 

Tufnell, 342 

Turnips, composition of, 116 

Typhoid fever, 214 (see Fever, Typhoid); 
fever bacilli in the oyster, 97; fever con- 
veyed by food, 202; fever conveyed by 
milk, 72; fever spread by impure cleansing 
water, 12 

Typhus fever, 220. See Fever, Typhus. 

Tyrotoxicon, 202 ; in cheese, 87 



Ulcer, gastric, 281; causes, 281; diet, 281; 
beef juices, 283; egg-albumin, 283; liquid 
foods, 283; milk exclusively, 282; milk 
preparations, 282, 283; hemorrhage in, 
treatment of, 281; prevention of, 281; 
resorcin as an adjuvant to diet, 282. 
Convalescence from, diet for, 283; treat- 
ment for, 283; water, alkaline, 281; water, 
hot, 284. With hyperchlorhydria, milk, 
pancreatized, 281; milk with Vichy, 281 

University boat crews, dietary for, 153 

Unripe fruit, composition of, 120 

Urea, effect of alcohol on, 141 

Uremia, 350; causes of, 350; cathartics, 350; 
dietetic regulation, 351; hygienic treat- 
ment, 352; hypodermoclysis, 351; milk, 
351; protein foods, 351; rectal feeding, 
351; rest, 352; water gruel, 351 

Uremia in chronic heart disease, 338; in 
yellow fever, 224 

Uremic mania, withholding of food, 351 

Urethritis from beer, 146 

Uric acid calculi, 345 (see Calculi, Uric 
{Acid); acid in gout and goutiness, 419; 
acid, migraine due to, 367 

Urine, casts in, from alcohol, 143 ; increased 
by milk diet, 79; indol in, from slow pro- 
tein digestion, 21; peptone in, 22; skatol 
in, from slow protein digestion, 21 

Urticaria, 380; dietetic faults, 380; fats to 
be limited, 27; idiosyncrasies, 380 

Utilization of food, 4 



fats in use, 28; food, starch of, 108; food, 
sugar of, 108; foods, 6; 107; foods, com- 
position of, 107; foods, digestibility of, 
107 (see also Food, Vegetable) ; oils and 
fats, absorption of, 107; origin of proteins, 
18; protein imperfectly digestible, 35; 
proteins, 109 

Vegetables for young children, 197; green, 
118; green, as antiscorbutics, 118, 201; 
green, cooking necessary, 118; composi- 
tion and food value of various kinds, 119; 
green, digestibility of, 118; green, harm- 
ful effects of, 118; insufficiency of, scurvy 
from, 201; iron content of, 293; laxative 
effects of, 118; percentages of sugar and 
carbohydrates in various kinds, 413; raw, 
infection from, 202; salts in, 109; small 
nitrogen value of, 107; water-content of, 
107 

Vegetarianism, 35, 59; harmful effects of, 35 

Venous infusion in cholera, danger from, 227 

Vichy, -.15, 274, 282, 319, 346, 414, 424 

Vinegar in salads, 128 

Virginia Hot Springs, 258, 259 

Voegtlin, 393 

Voit, 45 

Vomiting, 261; acute cases, 263; causes of, 
262; barley water for, 263; beef juice for, 
263; champagne for, 268; cracked ice for, 
263; during pregnancy, treatment of, 263; 
excessive, of pregnancy, nutritive ene- 
mata for, 263; feeding by teaspoon or 
medicine dropper, 262; in acute general- 
ized peritonitis, treatment of, 323; in 
appendicitis, treatment of, 310; in catar- 
rhal jaundice, treatment of, 317; in cere- 
brospinal meningitis, treatment of, 249; 
in cholera, treatment of, 226; in gastro- 
intestinal influenza, treatment of, 247; in 
intestinal obstruction, treatment of, 311; 
in pernicious anemia, treatment of, 296; 
in whooping cough, treatment of, 262; 
lavage for, 262; milk with lime water for, 
263; milk with sparkling water for, 263; 
nutritive enemata for, 261; reflex, 263; 
secondary, 262; strong coffee for, 262; 
withholding of food, 262. Tendency to, 
diet for, 262; cautious feeding, 262; dry 
foods, 262; foods to be avoided, 262 



Vals, 15, 346 
Valsalva, 342 
Vanilla, 128 

Vasomotor center, effect of alcohol on, 142 
Veal, chemical composition and fuel value 
of various cuts, 102; iron content of, 294 
Vedder, 400, 402 
Vegetable diet, exclusive, influence of, 23; 



W 

Walker-Gordon milk laboratories, 75 
Water, 7; absorption of, 9; abstinence from, 
deleterious effects of, 8; as a diaphoretic, 
10; as a diuretic, 10; daily consumption of, 
9; fattening by copious use of, n; hot, 
beneficial effects of, 10; drinking, impuri- 
ties of, 12; drinking, temperature of, 9; 



INDEX. 



449 



elimination of, 9; excessive use of, ill 
effects from, 8; essential to good elimi- 
nation, 10; for infants, 196; in wine, 147; 
percentage of, in milk, 68; purification, 
12; purification by boiling, 12; purifica- 
tion by filtering, 12; quantity of, needed 
in health, 8; sparing use of, at mealtimes, 
10; use of, by enema, 11; uses of, in 
cholera, 202; uses of, in dietetics, 7 

Waterhouse, J. H., 184 

Waters, hard, 13; soft, 13 

Waukesha Springs, 346, 359 

Wax beans, 117 

Weaning, 195 

Weber, 244 

Weight of athletes, diet and exercise to 
lessen, 152; of infants, attention to, 196 

West Baden, 274, 319, 346 

Wet nurse, rules for, 179 

Wheat, 293 

Wheat flour, 112; jelly, preparation of, 194; 
meal, 112; in Beri-Beri, 401 

Wheatena, 115 

Whey, 190; and cream mixtures, 190 

Whisky, 144 

White and Ladd, 190 

Whooping-cough, 248; convalescence from, 
249; diet for, 248; feeding in, 248; liquid 
and soft foods, 248, 249; vomiting in, 
treatment of, 248; coffee, 249; nutritive 



enemata, 248; oil inunctions, 348 

Wiesbaden, 17, 319 

Wiley, 123 

Williams, Mattieu, 86, 87 

Wine, 146; acids in, 147; alcohols in, 147; 
composition of, 147; composition of a few- 
kinds, 148; effects of, on digestion, 149 
effects of, on muscular work, 149; effects 
of, on persons of sedentary life, 149; 
ethers in, 148; flavors of, 147; glycerin in, 
147; harmful effects of, 149; making, 147; 
quality of, 146; sugars in, 148; sour, tannic 
acid in, 150; water in, 147 

Wines, artificial sparkling, 148; natural 
sparkling, 148 

Wood, 50, 57 

Wood, Charles D., 100 

Wood, H. C. 141 

Woodruff, Captain, 44 

Wort in malt mash, 145 



Yellow fever, 222. See Fever, Ycllmv. 
Yeo, I. Burney, 255 



Zasiadko, 360 

Zomotherapy in tuberculosis, 240 

Zwieback, 113 



29 



NOV 11 1912 






